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=V,

SURGICAL ESSAYS

/J/f

ASTLEY COOPER, F.R.S.

SURGEON TO GUY’S H03PIT

AND

BENJAMIN TRAVERS, F.R.S.

SURGEON TO ST, THOMAS7 S HOSPITAL.

PART II.

PRINTED FOR

LONGMAN, HURST, REES, ORME AND BROWN, PATERNOSTER ROW ;

E. COX, BOROUGH ;

. A. CONSTABLE AND CO. EDINBURGH ;

SMITH AND SON, GLASGOW; AND HODGES AND Mf ARTHUR,

DUBLIN.

1819

< -5

,fT

f f

G* WOODFALL, PRINTER, ANGEL COURT, SKINNER STREET,

LONDON

It was intended that an Essay , which Mr. Travers had
'prepared for this Volume , should have succeeded
Mr. Cooped s ; hut on account of the length of the
Paper on Dislocations , and of that contributed by
Mr. Travers , it has been judged better to reserve
it for a Third Part, which will appear in the course
of a few Months , and two short Essays of Mr. Coo-
ped s have been substituted for that of Mr. Travers.

CONTENTS*

Essay I. On Dislocations continued, and on Frac-
tures of the Hip and Knee-Joint.

Essay II. On Unnatural Apertures in the Urethra.

Essay III. On the Encysted Tumours,

Digitized by the Internet Archive
in 2017 with funding from
Wellcome Library

https://archive.org/details/b29326801_0002

On Dislocations continued.

CASES

DISLOCATIONS

OF THE

THIGH-BONE.

By Mr. ASTLEY COOPER.

IT is a curious circumstance, and one of which
I was informed by Mr. Cline, that Mr. Samuel
Sharpe, who was Surgeon to Qpy’s Hospital,
and had a large share of practice in this me-
tropolis, did not believe that a dislocation of
the thigh-bone ever occurred.

This want of knowledge in a very excellent
surgeon, for the time at which he lived, can
only be imputed to the few opportunities which
then offered of pursuing morbid anatomy, for
he must frequently have seen the accident in
the living subject, but never having examined
it in the dead, was led to believe that the ap-
pearances of dislocation had arisen from some
other cause.

Since the publication of my former essay on
Dislocations of the Thigh, the following cases
of this accident have occurred within my know-

ON DISLOCATIONS OF

ledge, the circumstances of which I shall shortly
detail from my notes, before I proceed to con-
sider the other objects of this essay.

CASE I.

Dislocation of the lejt Femur on the Dorsum Ilii .

James Ivory, aged 71, of Pottensend, Herts,
on the 7th of February, 1810, whilst working in
a clay-pit about twenty-five feet below the surface
of the earth, had a large quantity of clay fall
in upon him, while he was in the act of stooping
with his left knee bent rather behind the other,
and lie was in this situation buried under the
earth. He was however soon removed from his
perilous situation, and, being carried home, a
surgeon was immediately sent for, who, aware
of the accident being a dislocation, directly
employed some men to extend the limb, whilst
he attempted to push the head of the bone into
the acetabulum ; but all his efforts were unavail-
ing, as unfortunately for the patient pullies were
not employed. The appearances of the limb at
present, and it is now7 nine years from the
accident, are these; the limb is three inches
and a half shorter than the other, and the
patient is obliged to wear a shoe having an
additional sole of three inches on that side,
which lessens, though it does not prevent, his
halt in walking ; when he stands, the foot of
the injured limb rests upon the other ; the toes
are turned inwards, and the knee, which is ad-
vanced upon the other, is also inverted, and rests
upon the side of the patella of the sound limb

THE THIGH-BONE.

and upon the vastus internus ; it is also bent, and
cannot be completely extended. The thigh, from
the unemployed state of several of the muscles,
is very much wasted ; but the semitendinosus,
semimembranosus and biceps, owing to the
shortened state of the limb, form a considerable
rounded projection on the back part of the
thigh. The trochanter major is seven-eighths of
an inch nearer to the spine of the ileum on the
injured side than on the other. On viewing
him behind, the trochanter is seen to project on
the injured side much further than on the other ;
the situation of the head of the bone on the
dorsum ilii is easily perceived, and when the
limb is rotated inwards it is still more obvious.
The spinous processes of the ilia are of an equal
height. When sitting, the foot is turned very
much inwards, and the knee is placed behind the
other, whilst the toe only reaches the ground.
When fatigued he experiences pain in the op-
posite hip, and in the thigh of the injured
limb. This unfortunate man has an arduous
task to gain his bread by his labour, as he can-
not stoop but with the greatest difficulty, and
is therefore obliged to seek those employments
which least require that position. When he
attempts to take any thing from the ground
he bends the knee of the injured limb at right
angles with the thigh, and throws it far back.
He can now stand for a few seconds upon the
dislocated limb, but it was twelve months before
he could do so. When in bed it is painful to him
to lie on the injured side. His hip is, without any
apparent cause, much weaker at some times
than at others. When sitting down to evacuate

B 2

ON DISLOCATIONS OF

bis feces, he is obliged to support himself by
resting the injured knee against the tendo
achillis of the other leg, placing his right hand
on the ground. He now walks with two sticks ;
at first he employed crutches, and these he
used for twelve months, when he was enabled
to trust to one crutch and a stick, until his
limb acquired greater strength. In getting
over a stile, he raises the injured leg on two
steps, and then turns over the sound limb ; but
this he cannot accomplish when the steps are far
apart, and he is frequently obliged either to turn
back or to take a circuitous route. When lying
with his face downwards, the dislocated hip
projects very much upwards. He sometimes
falls in walking, and wyould very frequently do
so, but that he takes excessive care, as the least
push against him throws him down. The knee
being bent, part of the shortening of the limb
depends upon that circumstance. I give this
case to shew the evil that results from a disloca-
tion of the hip remaining unreduced ; and it
proves that dislocation of the thigh may occur
in a strong healthy man after he has arrived at
the age of sixty.

CASE II.

Dislocation of the Right Thigh hi the Foramen

Ovale .

A gentleman was thrown from his horse on
the 4th of January, 1818. The accident was
occasioned by the animal suddenly starting to
the right side, and endeavouring to keep his

THE THIGH-BONE.

seat by the pressure of the right thigh against
the saddle, he was thrown, and from the fall
received a severe contusion upon his head,
which produced alarming symptoms ; on the
following day it was observed that the right
thigh was useless, and that the knee was raised
and could not be brought into a straight line
with the other, having at the same time a di-
rection outwards, rendering it necessary to tie
it to the other knee ; the symptoms of injury
to the head precluded, at this time, the possi-
bility of an attempt at reduction. In fourteen
days he was so far recovered as to enable him
to sit up, and in a month he began to walk
with crutches. On November 1st, 1818, X first
saw him, and the appearances of the injured limb
then were as follows. The thigh was longer
than the other by the length of the patella j
the knee was advanced, and when in the recum-
bent posture, the injured leg could not be drawn
down to the same length with the other. The
upper part of the thigh-bone was thrown down-
wards, so as to render the hollow of the groin on
the injured side deeper than the other. The
toes were rather everted, but were capable of
resting on the ground when the body was erect,
though the heel could not. The head of the
bone could not be felt, and the trochanter was
much less prominent than usual ; when the
upper part of the thigh-bone was pressed against
the acetabulum, and moved, there was a sensa-
tion of cartilaginous rubbing, which, although
not easily described, is readily distinguished
from the crepitus occasioned by a fractured
bone. When sitting, the injured leg was two
inches longer than the other $ and to that degree

ON DISLOCATIONS OF

the knee was projected beyond the sound one.
In progression the knee was bent, and the body
being thrown forwards, he rested chiefly upon
his toe, and halted exceedingly in walking. The
sartorius and gracilis muscles were very much
put upon the stretch. At first he suffered much
from pain in the dislocated hip and thigh, but is
now free from pain unless he attempts to stand
on that limb only ; his toe at first was with diffi-
culty brought to the ground, but lie is now im-
proved in walking, for when he first made trial
with the assistance of a crutch and stick he could
not exceed half a mile, but is now capable of
walking two miles. In flexion his thigh admits
of considerable motion, but he cannot extend it
further than to bring the barn to the plane of the
other patella. The knees cannot be brought to-
gether, but he advances one before the other in
the attempt ; he can sit without pain, but the
jolting of a carriage hurts him exceedingly ; and
the attempt to sit on horseback produces ex-
cessive suffering. He cannot straighten his leg
when his body is erect, nor can he stoop to tie
his shoe on the injured side. Pain is produced
by resting on that hip in bed. No attempt was
made to reduce the limb ; the injury to the
head might have rendered it dangerous in the
commencement ; and at the time I saw him
there was no chance of success.

CASE III,

Dislocation on the Dorsum llii .

Mary Bailey, aged seven years, was admitted
into Guy’s Hospital June 16, 1819, under the

THE THIGH-BONE*

care of Mr. Astley Cooper, for a dislocation of
the os femoris upwards on the dorsum ilih
This accident was occasioned by the child
swinging on the shaft of a cart, which being
insecurely propt, suddenly gave way, and she
fell to the ground upon her side. The nature
of the accident was exceedingly evident ; the
limb on the dislocated side was at least two
inches shorter than the other ; the toe rested on
the tarsus of the opposite foot, and was turned
inwards ; the knee was also inverted, and rested
on the other. The child was admitted into the
hospital at half past five in the afternoon, the
accident having happened a little more than half
an hour. Where so little resistance was ex~
pected the pullies appeared unnecessary, and
towels were substituted, one being applied above
the knee and the other between the pudendum
and thigh, then bending the knee and bringing
the thigh across the other just above the knee,
gradual extension was made, and in about four
minutes the head of the bone suddenly snapt
into its socket. On the seventh day the child
was walking in her ward, and suffered little
inconvenience.

To Mr. Daniel, one of Mr. 'Lucas’s dressers,
I am obliged for the foregoing particulars ; he
having reduced the limb in the presence of
many of the students.

CASE IV.

Dislocation of the Head of the Thigh-hone into

the Ischiatic Notch ,

John Cockburn, a strong muscular man, aged

ON DISLOCATIONS OF

33, was admitted into Guy’s Hospital on the
3 1 st of J uly, 1819. While carrying a bag of sand
at Hastings on the 24th of June, he slipped and
dislocated the left hip-joint, and the following
is the account he gives of the accident ; that
the foot on the affected side was plunged sud-
denly into a hollow in the road, which turned
his knee inwards, when his body fell with vio-
lence forwards. Two attempts were made to
reduce the dislocation by pullies on the day
of the accident, which did not succeed, and it
was consequently repeated on the 27th of June,
which was also unsuccessful, although it was
continued each time nearly an hour. He was
directed to Guy’s Hospital by Mr. Stewart, sur-
geon at Hastings. It was found upon examina-
tion, after he had been admitted, that the thigh
was dislocated backwards into the ischiatic
notch, the limb was a little shortened, the knee
and foot were turned inwards, and the toe rested
on the ball of the great toe of the other foot ;
the head of the bone could not be felt, the
trochanter major was opposite the acetabulum,
the rim of which could be distinctly perceived.
The body being fixed, the thigh could be suf-
ficiently flexed nearly to touch the abdomen.
The patient was carried into the operating
theatre soon after his admission, and when two
pounds of blood had been taken from him, and
he had been nauseated by two grains of tar-

tarized antimony, extension was made with the

pullies in a right line with the body, and the
upper part of the thigh was raised while the knee
was depressed ; the extension was continued at
least for an hour and a half, during which time
he took two grains more of tartarized antimony.

THE THIGH-BONE.

bv which he was thoroughly nauseated ; the
attempts, however, at reduction, did not suc-
ceed. On the 3rd of August, the tenth day
from the accident, Mr. Astley Cooper succeeded
in reducing it in the following manner: He
ordered so much blood to be taken from the
arm as to produce a feeling of faintness. A
table was placed in the centre between two
staples, upon which the patient was laid on his
right side ; a girt was passed between the scro-
tum and the thigh, and carried over the pelvis
to the staple behind him; and thus the pelvis
was, as far as possible, fixed : a wetted roller was
carried around the lower part of the thigh just
above the knee, and a leather strap buckled on
it, to which the pullies were fixed, and to a staple
before the limb. The body was bent at right
angles with the thigh, and it crossed the upper
part of the other thigh : then the extension with
the pullies was begun, and gradually increased
until it became as great as tlfe patient could
bear. An assistant was then directed to get
upon the table, and to carry a strong band
under the upper part of the thigh, by which he
lifted it from the pelvis so as to give an oppor-
tunity for the head of the bone to be turned into
its socket. Mr. South, who held the leg, was
directed to rotate the limb inwards, and the
bone, in thirteen minutes, was heard to snap
suddenly and violently into its socket.

James Chapman,

Dresser at Guy’s Hospital , to \ whom I am m -
debted for the foregoing statement

ON DISLOCATIONS OP

I believe, in this case, I should not have sue-
ceeded,but from attention to two circumstances;
first, I observed that the pelvis advanced with-
in the strap which was employed to confine
it, so that the thigh did not remain at right an-
gles ; and I was obliged to bend the body for-
wards to preserve the right angle during exten-
sion; and secondly, the extension might have
been continued for any length of time, yet the
limb would never have been reduced but by the
rotation of the head of the thigh-bone towards
the acetabulum.

CASE V.

Dislocation of the Thigh Bone into the Iscliiatic

Notch .

DEAR SIR,

William Dawson, aged 34, on the 15th of
August, 1818, while spending his harvest-home
with several of his companions, became quarrel-
some with one of them, who threw him down,
and trod upon him. Upon extricating himself
and endeavouring to rise, he found some serious
injury to his right thigh rendering him incapable
of standing ; and in this state he was dragged
by his associates, for many hundred yards, into
a stable, where he lay till the next morning. I
then saw him lying upon a mattress, with the
hip and thigh, on the right side, prodigiously
swollen and painful ; and I was particularly
struck with the appearances of the knee and
foot on the same side, which were very much
turned inwards, but the limb was scarcely short-

THE THIGH-BONE.

ened. I ordered him to be carefully conveyed
home upon a shutter supported by six men, a
distance of about half a mile. From the im-
mense swelling and general enlargement of the
whole of the thigh, and of the soft parts around
the pelvis, it was impossible to ascertain exactly
the state of the injury; but it was fully im-
pressed upon my mind, that there was some un-
usual dislocation of the head of the thigh-bone.
He was accordingly ordered immediately to lose
blood both by general and topical means, with
emollient poultices to the whole of the swollen
parts ^ brisk purgatives were also administered,
succeeded by saline medicines, and a quiet
position enjoined for eleven days ; by which
time the swelling began somewhat to subside.
Still the precise nature of the injury was not
satisfactorily evident: but it was thought by Mr.
Nunn of Colchester, and Mr. Travis of East
Bergholt, who had kindly come over to wit-
ness it, that there was a luxation. The only
difficulty we had to reconcile this to ourselves,
was the belief, in our minds, that no author had
noticed this accident to have taken place with-
out an alteration in the length of the limb, ex-
cept it might be Mr. Astley Cooper, in his new
publication, which we neither of us had yet
seen. We accordingly had recourse to a mi-
nute examination of the skeleton; when we
immediately fancied we could account for this
sort of luxation not being attended with the
usual marked signs of displacement of the head
of the bone, excepting the knee and foot being
turned inwards ; for we noticed, that if the head
of the bone be luxated sideways into the ischiatic

ON DISLOCATIONS OF

notch, it would produce scarcely any difference
in the length of the limb. Trusting that a
little further delay might not be attended with
any material disadvantage, but give a chance
for the entire subsidence of all inflammation
and swelling, we proposed meeting again as soon
as we conveniently could, by which time we
might consult Mr. Cooper’s book. On Sunday
the 30th of August we accordingly met, which
was fifteen days after the accident, and from
the complete removal of all swelling the whole
of the femoral bone was satisfactorily traced to
its rounded head, which was lodged in the
ischiatic notch. Upon referring to the essays
which we had now before us, we had the
case delineated and described ; and as it
was exhibited in a plate, we had only to imi-
tate, in order to accomplish the reduction of
the bone. In the presence of two or three other
medical gentlemen who had now joined us, we
commenced the operation ; and as it would be
unnecessary to state every particular, after the
manner in which the position of the patient, the
fixing of the pullies and towels, are demon-
strated by this publication ; suffice it for me to
remark, that, after ten or twelve minutes’ gra-
dual extension, the reduction of the bone was
most readily and admirably accomplished.

Preparatory to commencing the operation,
we took thirty ounces of blood from the arm
ad deliquium , and afterwards, while fixing the
pullies, &c. we gave four grains of tartarized
antimony, at intervals, to produce nausea.* — Im-
mediately after the operation we gave one grain
of opium, applied sedative lotions to the parts.

TIIE TIIIGH-BONE.

and proceeding carefully for about a fortnight,
the patient was enabled to move about upon
crutches, and was shortly after sent home per-
fectly well.

I am,

JOHN ROGERS.

Manningtree,

August 1 5th, 1818.

REMARK.

The relation of the foregoing case, from the
kind manner in which Mr. Rogers has expressed
himself, may savour a little of vanity; but I shall
readily suffer this imputation, as my greatest
gratification will ever be to find that my humble
endeavours may in the slightest degree have con-
duced to the advantage of my professional bre-
thren, or to the benefit of those who may be
placed under their care.

The dislocation in the ischiatic notch has
been, as far as I know, in every author who has
written on the subject, incorrectly described :
for it had been stated, that the limb was length-
ened in this accident; and I need scarcely men-
tion the mischiefs in practice from so mistaken
an opinion ; but one I here must give. A gen-
tleman wrote to me from the country, in these
words : “ I have a case under my care of injury
to the hip; and I should suppose it a dislocation
into the ischiatic notch, but that the limb is
shorter instead of being longer as authors state
it to be this error must have arisen from their
having examined a pelvis separated from the
skeleton, and observed that the ischiatic notch

ON DISLOCATIONS OF

was below the level of the acetabulum when the
pelvis was horizontal — although it is above the
acetabulum in the natural oblique position of the
pelvis, at least as regards the horizontal axis of
the two cavities. It is to be remembered that
there is no such accident as a dislocation of the
hip downwards and backwards.

CASE VI.

Dislocation on the Dorsum Ilii.

MY DEAR SIR,

William Sharpe, an athletic young man, in
wrestling received a fall, his antagonist falling
with and upon him, their legs being so entan-
gled that he cannot say how he came to the
ground. He complained of great pain in the
hip, and was incapable of rising. About twenty
minutes after the accident I found him lying on
his belly in the field where it had occurred, and
the left limb in a trifling state of abduction,
shortened, and the knee and foot turned inwards,
the prominency of the trochanter gone, and the
head of the bone obscurely felt on the dorsum
ilii. He was conveyed home, and, in order to
reduce the dislocation, for such I considered it,
I placed the man on his right side diagonally
across a four-post bedstead. The centre of a
large sheet rolled up was placed at its extremi-
ties, passing in front and behind the body, and
fastened to the upper bed-post, as low as pos-
sible. The centre of a napkin, rolled in like
manner, was then applied upon the dorsum ilii,
between its crista and the dislocated bone $ and

THE THIGH-BONE.

each extremity being brought under the sheet
(forwards and backwards) was reflected over it
and tied in the centre, by which means I thought
to keep the pelvis secure ; the counter-extend-
ing force was applied above the ancle (it appear-
ing to me to interfere less with the muscles upon
the thigh:) first, rolling round a wetted towel,
and then, placing upon this the end of a long
or jack-towel: three men were now directed to
pull gradually and steadily; and when I per-
ceived the head of the femur was brought down
to the edge of the acetabulum, I raised it a little
with my clasped hands placed under the upper
part of the thigh, and immediately the head of
the bone entered the cotyloide cavity with a
smart snapping noise. The man had consider-
able pain about the hip and knee for some time,
but is now quite well.

I am. Dear Sir,

YoufS, truly,

HENRY OLDNOW.

Nottingham,

August 8th, 1819,

CASE VII.

Dislocation of the Ischiatic Notch .

Mr. Wickham, jun. of Winchester, had the
kindness to inform me of a case of this disloca-
tion which had been admitted into the Winches-
ter Hospital, under the care of Mr. Mayo, one
of the surgeons of that institution, whose per-
mission I have to state the following circum-
stances.

ON DISLOCATIONS OF

John Norgott, aged 40, was brought to the hos-
pital on 27th December, 1817, from the neigh-
bourhood of Alton; twelve days had elapsed since
the accident happened, without his being aware
of the nature of the injury* He reported that his
horse had fallen with him and on him, so that
one leg was under the horse, whilst his body was
in a half-bent position, leaning against a bank ;
lie was of middle stature, but very muscular; the
leg was but very inconsiderably shorter than the
other, and but little advancing over it; in fact,
the immobility of the limb was the chief criterion
of the dislocation ; for the head of the bone was
thrown into the ischiatic notch. The mode of
reduction was simple: Mr* Mayo had the limb
extended by the pullies, so as to bring the head
of the bone to the edge of the acetabulum, and
then tilted over it by a towel fastened round the
patients thigh, and neck of an assistant* The
man remained three or four weeks before he was
allowed to leave the house; but on the 4th of
February he was discharged, cured.

Winchester,

August 10, IS! 9.

CASE VIII.

Mr. Mayo also mentions the case of William
Hepdy, who came into the hospital in August
1812: the dislocation had taken place seven
weeks before, and was reduced the day after his
admission ; he was discharged, cured, on the
18th of November. This was a dislocation on
the dorsum ilii.

THE THIGH-BONE,

CASE IX.

Of Dislocation on the Dorsum IliL

Happening to be in Chester in September,
1818, I walked through the wards of the neat,
and apparently, to me, excellently conducted
infirmary of that city. Mr. Bagnall, surgeon in
Chester, mentioned to me a case of dislocation,
of the thigh upon the dorsum of the ilium,
which I immediately proceeded to examine.
The man’s name was John Chesers, and he
had been admitted under the care of Mr. Row-
lands ; the bone was dislocated upwards, the
affected thigh was shorter than its fellow, the
knee was inclined inwards and forwards, and
the foot pointed inwards ; every attempt to ro-
tate the foot outwards was productive of consi-
derable pain at the hip. When I had con-
cluded my examination of this case, I was in-
formed by Mr. Bagnall, that a man had been
admitted two months before under the care of
Mr. Bennett, one of the surgeons of the infir-
mary, with a dislocation of the thigh ; and
having requested of Mr. Bennett the particu-
lars of this accident, he was so kind as to send
me the following account.

CASE X.

Dislocation on the Dorsum llii .

John Forster, aged 22 years, was admitted
into the Chester Infirmary July 10th, 1818, with
a dislocation of the thigh on the dorsum iiii,

ON DISLOCATIONS OF

occasioned by a cart passing over the pelvis.
Upon examination I found the leg shorter than
the other, and the knee and foot turned in-
wards. The patient being firmly confined upon
a table, I extended the limb by pullies for fifty
minutes without success, and he was returned
to bed for three hours ; after which he was put
in the warm bath for twenty minutes, and the
extension was repeated for fifteen minutes un-
successfully; I therefore took twenty-four ounces
of blood from him, and gave him forty drops of
tinct. opii, continuing the extension, but not
succeeding in producing faintness, I gave small
doses of a solution of tartrite of antimony, which
in a quarter of an hour produced nausea ; in
ten minutes afterwards I succeeded in reducing
the limb, and in less than a fortnight he left the
infirmary quite well.* — Unfortunately, he began
to work hard immediately, and brought on an
inflammation in the hip, of which he has not
recovered.

S. R, BENNETT.

Chester .•

CASE XL

Dislocation on the Dorsum Hit.

Mr. Tripe, surgeon at Plymouth, has sent to
the Medico-Chirurgical Society, an account of
a case of dislocation of the thigh-bone on the
dorsum ilii, which had happened seven weeks
and one day prior to his making an extension
to reduce it, by which he was so fortunate as
to succeed in restoring the bone to its natural
situation.

the thigh-bone. 19

It appears then, by these examples, that in
eleven cases, seven were dislocated upon the
dorsum ilii ; three in the ischiatic notch ; and
one in the foramen ovale.

It is really highly gratifying to observe the
difference of knowledge in the Profession at the
present period when compared with that of fifty
years ago. What should we think of a surgeon
in the metropolis, in the present day, with all
his opportunities of seeing disease in the large
hospitals of this town, who doubted the existence
of a dislocation of the thigh, when we find our
provincial surgeons immediately detect the na-
ture of these injuries, and directly succeed in
their attempts to reduce them. Let them never
forget, however, that it is to their knowledge of
anatomy that they are indebted for this superb
ority, and, more especially, to morbid anatomy.

In my former essay I endeavoured to describe
the different situations into which the thigh*
bone is thrown in the dislocations of the hip-
joint, and the various appearances which these
luxations produce ; at the same time pointing
out what I have found to be the best means for
their reduction. It was then my intention to
have described the dislocations of the knee"
joint, but, upon more consideration, I thought
it better to continue the account of the injuries
incident to the upper part of the thigh-bone,
before I entered into a description of those of Contrasted

... . A with dislo-

other joints, because it would give me an op- cation,
portunity of directly contrasting the symptoms
which such fractures produce, with the distin-

c 2

ON FRACTURES OF THE NECK

Difference
of opinion.

Compara-
tive fre-
quency of
the two ac-
cidents.

Fracture of
two kinds,

guishing marks of dislocation, and thus enable
the young surgeon readily to discriminate the
one accident from the other. It must be con-
fessed that there is some difficulty in distin-
guishing the fractures of the hip-joint from its
luxations, and that much difference of opinion
subsists as to the process nature employs in the
restoration of these fractures ; for whilst one
surgeon maintains that all attempts to cure
them are unavailing, another asserts that they
admit of union like fractures of other bones of
the body. I shall therefore proceed to state
what has occurred to me upon these points,
both from my observation on persons suffering
under this accident, and my examination of
those after death, in whom this accident had
happened, as well as the effects which are pro-
duced by breaking the upper part of the thigh-
bone, in experiments on inferior animals*

FRACTURES OF THE NECK OF THE

THIGH-BONE.

Such accidents are more frequent than dislo-
cations of the os femoris, which is evinced by
the comparative number we admit into our hos-
pitals, being seldom without an example of the
fractured neck of the thigh-bone, whilst the
cases of dislocation upon the average do not ex-
ceed one in a year.

The fracture of the neck of the thigh-bone
is of two kinds: tirst, that in which the bone

OF THE THIGH-BONE.

is broken transversely through the cervix with-
in the capsular ligament ; and secondly, when
it is fractured externally to the ligament, either
through the root of the cervix or through the
trochanter major ^ the former of these may be
called the internal, and the latter the external
fracture, as regards the relative situation of* the
bone with respect to the capsular ligament.

Of the Fracture of the Neck of the Bone within
the Capsular Ligament .

The appearances which are produced by this
fracture are as follow : the leg becomes from
one to two inches shorter than the other, for
the junction of the trochanter major being de-
stroyed by the fracture, the trochanter is drawn
up by the muscles, and carries with it the neck
of the bone as high as the ligament will permit,
and consequently the trochanter rests upon the
edge of the acetabulum and upon the ileum
above it. This difference in the length of the
limbs is best observed by desiring the patient
to place himself in the recumbent posture on
his back, when, by comparing the malleoli, it
will be found that one leg is from one to two
inches shorter than the other ; but the retrac-
tion thus produced is easily removed, by draw-
ing down the shortened limb, when it will ap-
pear of the same length with the other ; but
immediately this extension is removed, the ac-
tion of the muscles quickly forces it into its
former position ; and this appearance may be

internal
and exter-
nal.

Diagnostic
marks of
fracture
within the
ligament.

Length.

22 ON FRACTURES OF THE NECK

repeatedly produced by extending the limb.
This evidence of the nature of the accident
continues until the muscles acquire a fixed
contraction, which enables them to resist any
extension which is not of the most powerful

Foot turned kind. Another circumstance which marks the

outwards.

nature of this injury, is the foot and knee being
turned outwards ; and this state depends upon
the numerous and strong rotatory muscles of
the hip-joint, which proceed from the pelvis to
be inserted into the thigh-bone, and to which,
very feeble antagonists are provided, a part of
the glutmus medius and minimus, the obtura-
tores, the pyriformis, the gemini and quadratus,
the pectinalis and triceps all assist in roll-
ing the thigh-bone outwards, whilst a part of
the glutseus medius and minimus, and the ten-
sor vagina femoris are the agents of the rota-
tion inwards. It has been denied that the
muscles are the cause by which this eversion is
produced, and it has been attributed to the
mere weight of the limb ; but any one may
satisfy himself that it is in part owing to the
muscles, by feeling the resistance which is made
to an attempt at rotation inwards of the neck
of the bone. This difficulty is also in some
measure attributable to the length of the cervix
femoris, which remains attached to the tro-
chanter major, because in proportion to its
length, by resting against the ileum it is pre-
vented turning inwards. Directly the bed-
clothes are removed, two circumstances strongly
arrest the attention of the surgeon, namely,
the diminished length of the injured limb, and
the eversion of the foot and knee. In the dis-

OP THE THIGH-BONE,

location upwards, the head and neck of the
bone prevents the trochanter from being drawn
backwards, whilst the broken and shortened
neck of the thigh-bone in the fracture of this
part readily admits it, and hence the reason
why the foot is inverted in the one case and
everted in the other.

Three or four hours must elapse before this
appearance is in its most decisive state, as the
muscles require some time to retract, and this
is the reason that the accident has been mis-
taken for dislocation. The surgeon having been
called directly after the accident had happened,
and before the muscles had acquired that fixed
state of contraction they afterwards possess, he
is led to mistake the nature of the injury ; and
from this cause patients, even in hospital prac-
tice, have been exposed to painful and useless
extensions.

The patient, when perfectly at rest in the Degree of
horizontal posture, suffers but little, but any pam’
attempt at rotation is painful, and more espe-
cially the rotation inwards, because the broken
extremity of the bone then rubs against the
lining of the capsular ligament, upon which it
is drawn by the action of the muscles. The
pain which is felt in this accident is in the up-
per and inner part of the thigh, opposite the
insertion of the iliacus and psoas muscles, into
the trochanter minor, or sometimes just below
this point. The perfect extension of the limb
may be easily effected, but flexion is more diffi- Degree of
cult and somewhat painful, and its degree de- mol,on’
pends upon the direction in which the bone is

ON FRACTURES OF THE NECK

Subdue tion
of the tro-
chanter.

Appear-
ances in the
erect posi-
tion.

bent, for if the flexion be outwards, it is ac-
complished with ease and but little suffering ;
but if it be attempted by directing the thigh
towards the pubes, the act of bending the limb
is with difficulty accomplished, and is attended
with very severe suffering, but it is easier or
more difficult in proportion as the neck of the
bone be shorter or longer.

In this accident the trochanter major is drawn
upwards towards the ileum, but the broken
neck of the bone attached to the trochanter is
placed nearer the spine of the ileum than the
trochanter itself, and in this situation it after*
wards remains ; by which alteration of position
the trochanter projects less on the injured side,
because it is no longer supported by the neck
of the bone as in its natural state, but rests in
close apposition to the ileum.

In order to form a still more decided judg-
ment of this accident, after the patient has been
examined in the recumbent posture, let him be
directed to stand by his bed-side, supported by
an assistant, so as to bear his weight upon the
sound limb ; immediately he does this, the sur-
geon observes most distinctly the shortened
state of the injured leg, from the toes resting
on the ground but the heel not reaching it, the
everted foot and knee, and the diminished pro-
minence of the hip ; then ordering the patient
to bear upon the injured limb, he finds himself
incapable of doing it but with considerable
pain, which seems to be produced by the psoas
and iliacus muscles being put upon the stretch
in the attempt, as well as by the pressure of

OF THE THIGH-BONE.

the broken neck of the bone against the capsu-
lar ligament*.

A crepitus, like that which accompanies other
fractures, might be expected to occur in these
accidents, but that is not the case when the
patient is resting on his back with the limb
shortened; but if the leg be drawn down, so
as to bring the limbs to the same length, the
crepitus is sometimes observed by the broken
ends of the bone being thus brought into con-
tact ; but the rotation inwards most easily de-
tects it. When the patient is standing upon
the sound limb, with the injured unsupported,
hy rotating it inwards the crepitus will some-
times be perceived.

To the circumstances I have already men-
tinned, as strongly characterizing this accident,
must be added the period of life at which it
usually occurs, for the fracture of the neck of
the thigh-bone within the capsular ligament
seldom happens but at an advanced period of
life. Old age, however, is a very indefinite
term ; for in some it is as strongly marked at
sixty as in others at eighty. That regular de-
cay of nature which is called old age, is at-
tended with changes that are easily detected in
the dead body; and one of the principal of
these is found in the bones, for they become
thin in their shell, and spongy in their texture.

The process of absorption and deposition
differ at different periods of life; in youth the
arteries, which are the builders of the body,

* The greater or less projection of the trochanter, how-
ever, will depend upon the length of the fractured cervLx
I'enjoris.

Crepitus,

Age,

Changes Ij%
age in the
bones.

ON FRACTURES OF THE NECK

Slight
causes of

this frac-
ture.

deposit more than the absorbents remove, and
hence is derived the great source of the growth
of the body* In the middle period of life the
arteries and absorbents so nearly preserve an
equilibrium of action, that with a due portion
of exercise the body remains in a stationary
state, while in old age the balance is destroyed
by the arteries doing less than the absorbents,
and hence the person becomes diminished in
weight, more from a diminution of arterial ac-
tion than from an increase of the absorbent.

This is well seen in the natural changes of the
bones, their increase in youth, their bulk, weight,
and little comparative change during the adult
period, and the lightness and softness they ac-
quire in the more advanced stages of life ; this
is so obvious, that the bones of old persons may
be cut with a pen-knife, which is capable of
making no impression on them at the adult
period? Even the neck of the thigh-bone in old
persons is sometimes undergoing an interstitial
absorption, by which it becomes shortened, al-
tered in its angle with the shaft of the bone, and
so changed in its form as to give an idea, upon
a superficial view, of its having been the subject
of fracture ; but it requires very little knowledge
of anatomy to distinguish in the skeleton the
bone of advanced age from that of the middle
period of life.

This state of bone favours much the pro-
duction of fractures, and the slightest causes
will often produce them in old age. In London
the most frequent source of this accident is from
a person, when walking on the edge of the ele-
vated footpath, slipping upon the carriage pave-

OF THE THIGH-BONE.

meet ; and though a distance but of a few
inches, from occurring so suddenly and unex-
pectedly, it produces a fracture of the neck of
the thigh-bone. I was informed by a person
who had sustained a fracture of this kind, that
being at her counter, and suddenly turning to a
drawer behind her, some projection in the floor
caught her foot, and preventing its turning with
the body, the neck of the thigh-bone was frac-
tured. A frequent cause of this accident is,
however, a fall upon the trochanter major ; but
X have dwelt particularly on the slight causes
which produce it, that the young surgeon may
be upon his guard respecting it, as he might
otherwise believe that so important an injury
could scarcely be the result of so slight an acci-
dent, and that excessive violence was necessary
to break the neck of the thigh-bone : such an
opinion is as liable to be injurious to his repu-
tation, as that of confounding this accident with
dislocation.

It very rarely occurs under fifty years of age;
and dislocation seldom at a more advanced pe-
riod, although there are exceptions to this rule:
for I have myself once seen this fracture at
thirty-eight years of age, and a dislocation of
the thigh at sixty-two; but between fifty and
eighty is the most common period: for, from the
different state of the bone, the same violence
which would produce dislocation in the adult
occasions fracture in age. But when dislocation
does occur between sixty and seventy years, it
is in persons whose constitutions are particu-
larly strong, and in whom age has not produced
those changes in their bones which 1 have ah*
ready endeavoured to point out.

ON FRACTURES OF THE NECK

Union of
this frac-
ture.

Much difference of opinion has existed upon
the subject of the union of the fractured neck
of the thigh-bone ; it has been asserted, that
these fractures unite like those of other parts of
the body; but the dissections which I made in
early life, and the opportunities I have since had
of confirming these observations, have convinced
me that the transverse fracture of the cervix
femoris within the capsular ligament, does not
unite by bone, a circumstance which I have
always taught in my lectures ; this is a most
essential point, as the reputation of the surgeon
hinges upon it. I was called to a case of this
fracture, in which the medical attendant had
been promising, week after week, an union of
the fracture, and the restoration to the patient

of a sound and useful limb. After many weeks

the person became anxious for further advice ;
I did all in my power to lessee the nature of the
mistake this' gentleman had made, by telling the
patient she would probably ultimately walk, al-
though with some lameness ; and taking the
surgeon into another room, asked him upon
what grounds he was led to suppose there would
be union; to which he replied, he was not aware
but the fracture of the neck of the thigh-bone
would unite like those of other bones of the
body ; the case, however, proved unfortunate
for his character, as this patient did not recover
in the degree they usually do. Young medical
men find it so much an easier task to speculate
than to observe, that they are too apt to be
pleased with some sweeping conjecture, which
saves them the trouble of observing the proces-
ses of nature ; and they have afterwards, when
they embark in their professional practice, not

OF THE THIGH-BONE.

only still every thing to learn, but also to aban-
don those false impressions which hypothesis is
ever sure tQ create, before they can be safely
trusted'. — Nothing is known in our profession
by guess : and 1 do not believe, from the first
dawn of medical science to the present mo-
ment, that a single correct idea has ever ema-
nated from conjecture : it is right, therefore,
that they who are studying their profession should
be aware that there is no short road to know-
ledge ; and that observations on the diseased
living, examination of the dead, and experi-
ments upon living animals, are the only sources
of true knowledge ; and that induction from
these are the sole basis of legitimate theory.

In all the examinations which I have made of
transverse fractures of the cervix femoris en-
tirely within the capsular ligament, I have
never met with a bony union, or of any which
did not admit of motion of one bone upon the
other. To deny its impossibility would be pre-
sumptuous, under all the varieties of direction,
extent of fracture, and degree of violence by
which it has been produced, for there is scarcely
a general rule which does not admit of excep-
tion ; but, all I wish to be understood to say is,
that if it ever does happen, it is an extremely
rare occurrence, and that I have not yet met
with a single example of it*.

Having thus stated what is the common re- Cause of

. the want of

suit or these cases, as regards their want of union.

* In Mr. Cross’s account of his visit to the French Hos-
pitals, some interesting matter upon this subject will be
found.

ON FRACTURES OF THE NECK

Want of

proper ap-
position.

union, ^ I shall now proceed to give the rea-
sons which may be assigned for the absence
of ossilic union in the transverse fracture of
the neck of the thigh-bone within the capsular
ligament.

The first reason which I should state is
the want of proper apposition of the bones ;
for if the broken extremities be in any part
of the body kept asunder, ossific union is pre-
vented.

A boy, who had a compound fracture of the
tibia, without the fibula being broken, and
having the protruded end sawn off, the two
extremities were prevented from coming in
contact by the fibula, and union never oc»
curred. — My friend, Mr. Smith, an excellent
surgeon at Bristol, had a similar case under
his care, in which a portion of the tibia had
been sawn off8, and the fibula remaining whole,
prevented ossific union*.

# The particulars of the case were as follows : — The boy
was admitted into the Bristol Infirmary for disease of the
tibia ; and the diseased portion not extending more than from
two to three inches in length, that part of the bone was re-
moved by the saw. In a month the limb had acquired so
much firmness, that the boy was permitted to walk about the
ward, which he was able to perform tolerably well, and in six
weeks no doubt was entertained of ossification having taken
place in the uniting substance; at this time he sickened with
the small-pox, and died. — Upon examination, the edges of the
extremities of the tibia were absorbed and rounded, and on
the inferior portion a bony callus had formed, about three-
quarters of an inch in extent; no earthy matter was discover-
able in the greater part of the space originally occupied by
the diseased bone, but a tough though thin ligamentous band
extended from the superior to the inferior portion of the tibia.
See Medical Records and Researches.

OF THE THIGH-BONE.

This fact is easily seen by experiment on
other animals; I sawed seven-eighths of an inch
of the radius from a rabbit, and the ends of the
bones were not united to each other, but only
to the ulna. In another rabbit I took out one-
ninth of an inch of the radius with the same re-
sult ; I also sawed off the extremity of the os
calcis, and suffered it to be drawn up by the
action of the gastrocnemius muscle, and it
united only by ligament. See Plate.

The neck of the thigh-bone, when broken, is
under similar circumstances ; for, by the con-
traction of the muscles it is no longer in apposi-
tion with the head of the bone, and is therefore
prevented uniting ; but if this were the only
obstacle, it would be argued that the retraction
of the thigh-bone might be prevented by ban-
daging and extension : and the truth of this
cannot be denied, although it is extremely diffi-
cult to preserve the limb in this position, as the
patient in evacuating his ffoces and urine, or by
the slightest change of position, produces instant
contraction of the limb, by calling into action
those powerful muscles which pass from the
pelvis to the thigh-bone.

The second reason which prevents a bony
union in these fractures, is the want of pressure
of one bone upon the other, even where the
length of the limb is preserved ; and this I con-
sider as the principal cause, and which will
operate in preventing an ossific union in all
cases where the capsular ligament is not torn ;
and in those I have had an opportunity of
examining it has not been lacerated. The cir-
cumstance to which I allude, is the secretion of

Abseiace <r»F

continued

pressure.

ON FRACTURES OF THE NECfc

a quantity of fluid into the joint ; from the in-
creased determination of blood to the capsular
ligament and synovial membrane, a superabund-
ance of serous synovia, that is, synovia much
less mucilaginous than usual, distends the liga-
ment, and entirely prevents the contact of the
bones, by pushing the upper end of the body of
the thigh-bone from the acetabulum. After a
time, this fluid becomes absorbed, but not until
the inflammatory process has ceased, and liga-
mentous matter has been effused into the joint,
from the interior of the synovial membrane*
That pressure between the broken extremities
of bones is necessary to their union is further
shewn by the following circumstances. If two
broken bones overlap each other, on that side on
which they are pressed together, there is an
abundant ossiflc deposit ; but on the opposite
side where there is no pressure, scarcely any
change is observed. So also wre find if the ends
of the bone be drawn from each other by the
action of muscles, as sometimes happens in the
fractures of the Os Femoris, Tibia, Os Humeri,
Radius et Ulna, that union is not effected until
the surgeon, by a strong leather bandage tightly
buckled around the limb, compels the bones to
press upon each other, and thus support the
necessary inflammation for the production of
ossiflc union. When a fracture occurs amidst
muscles, those which are inserted into the frac-
tured part of the bone have generally a tendency
to keep the extremities of the bones together,
with some few7 exceptions; but when a fracture
occurs in the neck of the thigh-bone, the mus-
cles have only an influence upon one portion of

THE THIGH-BONE*

the fractured bone ; and this influence serves to
draw one part from the other.

The third reason which may be assigned for
the want of union of this fracture, is the little
action proceeding in the head of the thigh-
bone when separated from its cervix, its life
being solely supported by the ligamentum teres
which has some few vessels ramifying from it to
the head of the bone. Little effusion of car*
tilage takes place, and but little bone is thrown
out to fill the cancelli; yet it is certain that when
the patient begins to employ the limb, the one
portion of bone is occasionally applied against
the other, and it would therefore be expected
that a greater change in the head of the bone
should take place ; but on account of its slight
vital power, this is not found to be the fact. X
must observe, however, from the same circum-
stances happening in fracture of the patella,
that want of apposition and pressure are the
principal causes of the absence of union in the
fracture of the neck of the thigh-bone. . But
still it must be allowed that the changes which
are taking place in the head of the bone, after
this fracture, are less than those which occur in
any other fracture in the body, excepting in
that of the patella, and that they seem even to
differ in kind, because, instead of the common
cartilaginous effusion which always precedes
the formation of bone, a large quantity of liga-
mentous matter is thrown out from the surface
of the cancellated structure upon the head of
the thigh-bone.

The appearances which are found on the
dissection of these injuries are as follow :

Little ac-
tion in the
head of the
bone.

ON FRACTURES OF THE NECK OF

niwecfioo The head of the bone remains in the acetate-

ture. luni attached by the ligamentum teres. There
are, upon parts of the head of the bone, very
small ossific deposits, covered by the articular
cartilage.

Bon*. The cervix is sometimes broken directly trans-

versely, at others with obliquity* The cancel-
lated structure of the broken surface of the
head of the bone and of the cervix is hollowed
by the occasional pressure of its neck attached
to the trochanter, and consequent absorption ;
and this surface is sometimes partially coated
with a cartilaginous deposit, which is in some
parts studded with slight depositions of ossific
matter in spots, so as to fill the cancelli, and
produce a structure of a yellow colour upon
the bone, which is rendered firm and smooth
by friction, as we see in other bones which rub
upon each other when their articular cartilages
are absorbed. Portions of the head of the bone
sometimes are broken off, and these are found
either attached by means of ligament, or float-
ing loosely in the joint covered by a ligamen-
tous matter ; but these pieces do not act as ex-
traneous bodies, so as to excite inflammation,
and thus produce their discharge, any more
than those loose portions of bone covered by
cartilage, which are found so frequently in the
knee, and sometimes in the hip and elbow
joints. Some ossific matter is effused on die
neck of the bone connected with the trochan-
ter, which is rendered short by an absorbent
process ; so as in some cases scarcely to project
beyond the trochanter. (See Plate.) The ap-
pearance of the cancelli of the cervix femoris

THE THIGH-BONE.

differs much after this accident, being in some
cases scarcely filled, and in others partially co-
vered by a thin pellicle of cartilage, which, re-
ceiving afterwards an ossific deposit, puts on a
yellower appearance than the original bone, and
is smooth on its surface ; generally, however,
the cancelli are also partially covered by a liga-
mentous structure.

The capsular ligament enclosing the head
and neck of the bone becomes much thicker
than natural, but the synovial membrane which
lines it undergoes the greatest change from in-
flammation, being very much thickened, not
only where it lines the capsular ligament, but
also upon the neck of the bone, as far as the
edge of the fracture.

Within the articulation a large quantity of
serous synovia is found ; by which term I mean
to express, that the synovia is less mucilaginous,
and contains more serum than usual : this fluid,
by distending the ligament, separates for a time
one portion of bone from the other ; it is pro-
duced by the inflammatory process, and be-
comes absorbed when the irritation in the part
subsides. I do not know the exact period at
which this change takes place, but have seen it
in the recent state of the injury. Into this fluid
is poured a quantity of ligamentous matter, by
the adhesive inflammation excited in the syno-
vial membrane, and flakes of it are found pro-
ceeding from its internal surface, uniting it to
the edge of the head of the bone. Thus the
cavity of the joint becomes distended in part by
an increased secretion of synovia, and in part by
the solid effusion which the adhesive inflamma-

D 2

Ligament
and syuo-
vial mem-
brane.

Effjsiftn
into the
joint.

New liga-
ment.

ON FRACTURES OF THE NECK OR

Union by
ligament.

Experi-

ments.

tion produces: the synovial membrane reflected
on the cervix femoris is sometimes separated
from the fractured portions, so as to form a band
from the fractured edge of the cervix to that of
the head of the bone; bands also of ligamentous
matter pass from the cancellated structure of
the cervix to that of the head of the bone, serv-
ing to unite, by this flexible material, the one
broken portion of bone with the other.

The trochanter is drawn up, more or less, in
different accidents ; and in those cases in which
it is very much elevated, I have known a consi-
derable ossific deposit take place upon the body
of the thigh-bone between the trochanter major
and trochanter minor. When the bone has been
macerated, its head and cervix are much lighter
and more spongy than they are in the healthy
state, excepting on those parts most exposed to
friction, where they are rendered hard by a slight
deposition of ossific matter, which has sometimes
a polished surface.

It appears then, from this account of the dis-
section of those whose bodies are examined after
having suffered from this fracture, that no ossific
union is produced ; that nature makes slight at-
tempts for its production upon the neck of the
bone, and upon the trochanter major; but scarce-
ly any upon the head of the bone ; and that if
any union be produced, it is by ligament only.

These circumstances, which I have stated for
many years in my lectures, and supported, a3
far as I was able, by the dissection of these
fractures in the human subject, led me to pro-
secute the inquiry by experiments upon other
animals. I found it difficult to succeed in

THE THIGH-BONE.

breaking the bone in the direction I wished ;
and after a great number of experiments, was
only in four instances successful ; the prepara-
tions of which 1 have preserved. (See Plate.)

EXPERIMENT I.

The neck of the thigh-bone was fractured in
a rabbit, on October 28th, 1818; and on De-
cember 1st, 1818, as the wound had been some
time healed, I dissected the animal®

Appearances on Dissection.— The capsular li-
gament was much thickened, the head of the
bone was entirely disunited from its neck, but-
adhered by ligament to the capsular and syno«
vial membranes; the broken cervix, which was
very much /shortened, played on the head of the
bone, and had smoothed it by attrition ; the
head of the thigh-bone had not undergone any
ossific change.

EXPERIMENT II.

The neck of the thigh-bone was broken in a
dog, November 12th, 1818, and the animal was
killed on the 14th of December following.

Dissection.— The trochanter was much drawn
up by the action of the muscles, so that the
head and cervix were not in direct apposition.
The capsular ligament was much thickened, and
contained a large quantity of synovia.

The joint was lined by adhesive matter of a
ligamentous appearance, adhering to the head
of the bone, which did not seem to be changed
by any ossific process ; but the thigh-bone

ON FRACTURES OF THE NECK OF

Lon git mil-
nal fracture.

around the capsular ligament, and the trochan-
ter major, and a little below it, was enlarged ;
we find, therefore, by this dissection, what ap-
pears in the human subject after this accident,
happens in other animals ; and motion, want of
apposition, and pressure, with the little ossific
action, in the head of the bone under these
circumstances, produce the deficiency of bony
union, as in man.

Having ascertained this, I was next anxious
to learn if the head and neck of the thigh-bone
would unite under circumstances in which ap-
position and pressure were maintained ; and for
this purpose made the following experiment :

EXPERIMENT III.

I divided the neck and head of the thigh-bone
longitudinally, by placing a knife on the ante-
rior part of the trochanter major, and striking if
down towards the acetabulum. The dog was
killed twenty-nine days after, and the following
appearances presented themselves :

A portion of the trochanter major had been
broken off, and was only united by cartilage ; the
head and neck of the bone which had been lon-
gitudinally broken, were united ; but the neck
was joined by a larger quantity of ossific deposit
than that which joined the separated portions of
the head of the bone, and so irregularly as to
make a beautiful preparation, and shews the
circumstance most clearly. (See Plate.) This
bone may be seen in the collection at St. Tho-
mas’s Hospital. — Whether the union began ex-

1 O

ternal ly to the ligament, and proceeded inwards.

TUI THIGH-BONE.

or whether on the whole surface at once, it is
impossible to ascertain ; but the coalescence was
firm, though, as I have stated, I thought more
so at the neck than at the head of the bone.

Thus, then, it appears, that if the bones be
applied to each other, if they be pressed to-
gether, and in a state of rest, ossific union can be Union of
produced in a longitudinal fracture, although
the ossific deposition is extremely slight when
compared with that of other bones. This prin-
ciple will be further explained by experiments
on the fracture of the patella. The great differ*'
ence, between the longitudinal and the trans-
verse fracture of the cervix femoris, consists
in this, that in the longitudinal, as both parts of
the head of the bone are remaining in the aceta-
bulum, they are pressed firmly together, and
this contact produces their union, even under
the slightest ossific action $ beside which, the
broken head and neck of the bone have sources
of nourishment independent of the ligamentum
teres ; whilst, in the transverse fracture, the
actions of the muscles have a constant tendency
to separate the portions of bone, and the effu-
sion of synovia and of ligamentous matter into
the joint, prevent a continued contact of the
fractured surfaces of the bones.

The fracture of the neck of the thigh-bone
may be confounded with the dislocation of the
os femoris upon the dorsum ilii, in the ischiatie
notch, and upon the pubes ; as in all of these
the limb is shorter.— From the two former, it
may be distinguished by the eversion of the
foot, and by the flexibility of the limb in the
fracture j. and from the latter, by the bail of

ON FRACTURES OF THE NECK OF

Treatment,

the os femoris being felt in the groin, which
happens in the dislocation on the pubis; other-
wise the eversion of the foot in both cases
might lead to their being confounded. — (See
Essay on Dislocation, in the first Part.)

With respect to the treatment of the fractured
cervix femoris within the capsular ligament,
those who believe a union can be effected after
a transverse fracture, will extend the limb so as
to bring the bones in apposition by drawing
down the trochanter, and by applying splints
upon the thigh, and straps around the pelvis, to
force the cervix femoris against its head ; and
the best means for the purpose will consist of an
apparatus described in the succeeding pages, and
delineated in one of the plates. And some sur-
geons have thought that in this wray their efforts
have been effectual in producing an union : but,
from the history of the cases, it is clear they
have not distinguished the fracture within, from
that which is external to the ligament, in which
union of the bone occurs as in other bones of the
body: those, on the contrary, who have observed
these accidents well, who see the fracture oc»
c urring at very advanced age, who only dis-
cover a crepitus when the bone is drawn down
and rotated inwards, in whom the limb is con-
siderably shortened, and the degree of pain they
suffer comparatively slight to the fracture of the
body of the bone, will be disposed to avoid con-
fining the patient to any long or continued ex-
tension as being likely to be productive of ill
health, without the probability of producing
union.— -Tiie mode, therefore, wdiich we now
adopt in these cases, is as follows We place a

THE THIGH-BONE®

pillow under the whole length of the limb, and
put another across this under the patient’s knee;
and thus, by keeping it elevated, we procure an
easy bent position of the limb : in this situation
the patient remains, until the inflammatory pro-
cess consequent to this accident, has ceased,
which is from a fortnight to three weeks ; we
then allow the patient to rise from her* bed, and
to sit upon a high chair, to prevent a degree
of flexion which would be painful ; in a few
days crutches are allowed, upon which the pa-
tient is then capable of taking exercise ; after
a time the crutches may be laid aside, a stick
substituted for them, and in a few months the
person is able to use that limb without any
adventitious support. The degree of recovery, Degree of
in these cases, is as follows : if the patient be re< overy*
very corpulent, the aid of crutches will be for a
long time required; if less bulky, a stick only
will be sufficient ; and where the weight of the
body is inconsiderable, the person is able to walk
without either of these aids, but drops a little at
each step on that side, unless a shoe be worn
having a sole of equal thickness to the dimi-
nished length of the limb. In every case, how-
ever, in which there is the smallest doubt,
if it be a fracture within, or external to the
ligament, it will be proper to treat the case
as if it were the fracture which I shall next de-
scribe, and which readily admits of union.

Now and then this accident is destructive to Danger of.
life in very old and infirm persons, from the ex-
hausted state of their frame.

} x

* This accident more frequently occurs in the female than
jn the male.

ON FRACTURES OF THE NECK OF

Symptoms.

The surgeon must be careful of the opinion
which he gives of the result of these cases; lame-
ness is, in the transverse fracture, sure to follow;
but its degree cannot, at the first of the accident,
be exactly estimated.

it is gratifying to find opinions which have
been long delivered, confirmed by the obser-
vations of intelligent and observing persons ;
and therefore it was with pleasure I read the ac-
counts of the dissection of several cases of frac-
ture of the cervix femoris, by my friend Mr.
Collis, (who is a man excellently informed in
his profession,) and who has published in the
Dublin Hospital Reports, the dissection of seve-
ral of these accidents, and found a similar want
of ossific union in the fracture within the liga-
ment.

Of Fractures of the Cervix Femoris external to

the Capsular Ligament .

The symptoms of.this accident in some re-
spects so closely resemble those of the fracture
internal to the ligament, as to require much
attention to accurately distinguish them ; but
the result is entirely different : so that a favour-
able opinion may be given as to the restoration
of the bone by an ossific union.

In this accident the injured leg is a little
shorter than the other ; the foot and toe on that
side are everted, from the loss of support which
the body of the thigh-bone sustains in conse-
quence of the fracture ; much pain is felt at the
hip, and on the inner and upper part of the thigh*

THE thigh-bone.

}

and the joint losea its usual roundness. These,
then, are all marks of similarity between the two
accidents; but still there are many distinguishing
signs. First; This accident occurs frequently at
the earlier periods of life ; for it happens in the
young, and in the adult under fifty years of age;
I have known it at a later period, but less fre-
quently; therefore, when the above symptoms
are seen at any age under fifty years, it will be
generally found to be a fracture external to the
capsular ligament, and capable of having ossific
union produced in it, and, consequently, of com-
plete recovery.— The first case of this accident I
ever saw, was in a man of middle age, at St.
Thomas’s Hospital, under Mr. Cline, senior, who
had most of the symptoms of a fractured cervix
femoris within the capsular ligament. He was
placed in bed with his thigh extended over a
pillow, and splints were applied ; the man re-
covered with an ossific union, which was ascer-
tained by dissection, as he died of a fever at the
period at which he was to have been discharged
from the hospital ; and upon examination of
the limb, the thigh-bone was found united ;
the fracture having been external to the cap-
sular ligament through the trochanter major.

These cases may be in some measure distin-
guished by the severity of the accident which
produces them, whilst the internal fracture, as
we know, happens from very slight causes, this,
on the contrary, is produced either from severe
blows, from falls from a considerable height, or
from laden carriages passing over the pelvis.

It may be also generally known by the crepi-
tus which usually attends it upon slight motion,

Diagnostic

marks.

Union of
the bone.

Causes

severe.

Crepitus,

ON FRACTURES OF THE NECK OF

Trochanter
cTravvn
forwards
more than
upwards.

Hollow of
the groin
filled.

Severe

pain.

Tirol) vrry
Tittle short-
er.

Rotation

greater.

for it is rarely necessary to draw the limb down*
to distinguish the grating of one bone upon the
other, and this happens from the less retraction
of the limb ; I have however seen a case where
the crepitus could not be discovered unless the
thigh was extensively moved.

The broken trochanter is in these cases drawn
forwards, so as to be placed before the head of
the bone nearer to the spine of the ileum than it
is naturally seated. When the patient is sitting,
on the healthy side, there is naturally a depres-
sion in the groin, into which the hand readily
sinks, but upon the fractured side this is not the
case, for that part is occupied by the extremity
of the broken bone, forming a prominence there,
which is very distinct.

This accident is generally marked by much
greater severity of suffering than the fracture
within the ligament, more especially upon mo-
tion, for then the broken ends of the bone rub
violently against the muscles, and produce ex-
cruciating pain, which does not happen in an
equal degree in the fracture within the ligament.

The limb is shorter, but .not to the same ex-
tent as in the internal fracture, for it rarely
amounts to an inch ; this, however, will greatly
depend upon its obliquity, and upon the degree
of laceration of the surrounding parts, admitting
of a greater or less retraction of the muscles.

In the external fracture, the rotation of the
limb is more extensive than in the internal, be-
cause there is no cervix remaining attached to
the shaft of the bone. If the upper part of the
trochanter major be fixed at the time the body
of* the bone is rotated, and the fracture is through

THE THIGH-BONE

the trochanter, the rotation of the thigh may be
performed without giving motion to the cervix
femoris.

Lastly, this accident may be distinguished by
the ossific union which occurs in it, but this can
only be ascertained at the distance of from eight
to twelve weeks from the time of the injury*

Upon the dissection of these cases, the seat of
the fracture is found to vary, sometimes it is at
the part at which the cervix joins the trochanter
major. Mr, Travers shewed me a specimen of
this accident, in which the bone was divided into

several portions. First, the trochanter minor
was detached from the shaft of the thigh-bone*
Secondly, an oblique fracture passed through
the trochanter major, so as in part to detach it
from the body of the bone. Thirdly, the head
and cervix femoris were broken from the tro-
chanter, and the fracture passed in part exter-
nally and in part within the capsular ligament*

My friend Mr. Roux, sent me from Paris one
of these cases, which was broken through the
junction of the cervix with the trochanter, in-
cluding a part of the latter. (See Plate.) In
another plate, the fracture will be seen extending
obliquely from the trochanter minor through
the trochanter major, and the drawing is from
a bone which has been long in my possession,
and which is now in the Museum at St. Tho-
mas's Hospital ; it appears in this case, the
thigh had been placed on its outer side du-
ring union, as it has united with the condyles
exceedingly everted* Mr. Oldnow, surgeon at
Nottingham, sent for my inspection two excel-
lent specimens of this fracture, in which the
neck of the thigh-bone was broken at its junction

Ossifle
mi. on.

Dissection.

ON FRACTURES OF THE NECK OP

Difference
of opinion
reconciled.

with the trochanter major. The trochanter ma-
jor itself was also broken off; the trochanter mi-
nor formed a distinct fracture; the broken cervix
femoris had become united to the shaft of the
bone ; the trochanter minor was reunited to
the thigh-bone, but was drawn higher than its
natural situation.' The trochanter major was in
one of the specimens, completely united to the
body of the bone, but not in the other. Thus the
thigh-bone, at the trochanter, was divided into
four parts, viz. the head and neck as one part, the
trochanter major as a second, the trochanter
minor as a third, and the body of the bone mak-
ing the fourth ; the bones uniting with very
little shortening.

Although, then, this accident has some of
the marks of the internal fracture of the neck of
the bone, yet it unites by bone, and it will be
seen that the union is similar to that of other
bones external to the joints ; cartilage is first
deposited, and then the matter of bone, because
in this case it can be brought into apposition,
and the ends of the bones are confined together
by the surrounding muscles; one portion is
pressed against the other, and the neck of the
bone sinks deeply into the cancellated structure
of the trochanter, and thus direct approach and
pressure are preserved when the fracture is at
the junction of the cervix with the trochanter,
and the nutrition of each extremity of the bone
is well supported by the vessels which proceed
to it from the surrounding parts.

We now see the reason of the difference of
opinion respecting the union of the fracture of
the neck of the thigh-bone. In the internal the
bones .Ire not applied to each other, and the

THE THIGH-BONE.

nutrition of the head of the bone is imperfect,
but in the external the bones are held together
by the surrounding parts, and easily kept so by
external pressure.

Much time is required in some of these acci-
dents to produce a complete ossific union ; and
the head and neck of the bone received into the
cancel!! move for a long period in their new situ-
ation, although so far locked in as to prevent their
separation. Mr. Travers has the most valuable
specimen of this state of the bone which I have
had an opportunity of seeing, and of which he
has had the kindness to send me the following
account :

“ Richard Norton, aged 60, fell upon the
curb-stone of the foot pavement, and struck
the upper and outer part of his left thigh with
great violence. He was admitted into St. Tho-
mas’s Hospital on the 24th of January, 1818.
The tension was then considerable ; the line of
the tensor vaginal femoris formed an arch, the
limb was shortened, the foot inclined outwards;
the motion of the limb free in all directions ;
but it was painful, more especially when the
knee was carried over the opposite thigh. The
crepitus of the trochanter major was distinctly
felt in these motions, and the swelling of the
parts, with the extensive crepitus, gave an idea
that the accident was a comminuted state of the
trochanter, and that the base of the cervix fe-
moris was broken, hence the shortening of the
leg and the eversion of the foot. After the use of
evaporating lotions, for some days the tension
subsided, so as to allow of the application of
the long outer splint and two thigh splints
well bedded. On the 4th of March the splints

ON FRACTURES OF THE NECK Qp

were removed, and union appeared to hav^
taken place, for the limb had resumed its natu-
ral figure, but was a little shorter than the other.
In the course of a month more he began to use
his crutches. On the 15th of April he was
placed under the physician, for defect in his
general health; and when he was upon the point
of quitting the hospital he was seized with spasms
in his chest, of which he suddenly expired.

“ Upon examination, some old adhesions of
the pleura and water in the chest and peri-
cardium were found. The fracture was through
the trochanter, as had been supposed, extend-
ing some way down the bone, and it apparently
had united, with very slight deformity ; but on
maceration, the head and neck of the bone be-
came loose in the thigh bone, and a fracture
was found there, which locked the head and
cervix in a shell of bone formed around them.

6t B. TRAVERS.”

•i f

.■» , .. * <

Mr. Travers having sent me the bone, the
following are the appearances of this curious
case. The head and cervix had been separated
from the trochanter major and body of the bone.
The upper part of the thigh-bone was obliquely
split, so as to receive the cervix femoris into
the cancelli. This fracture of the thigh-bone
separated the posterior portion of the trochanter
major from the body of the thigh-bone, and the
trochanter minor was removed with it. An union
had taken place between the fractured portions
of the trochanter, at a slight distance from each
other, and thus a hollow was left, into which
the cervix femoris was received, and it had not
yet become united by ossifie deposit, for upon

THE THIGH-BONE.

maceration the neck of the bone had free play
in the cavity in which it had been received, and
from which it could not be removed.

In the treatment of this injury we used to
preserve the length of the limb by applying a
roller around the foot of the injured leg, and
by binding the foot and the ancles firmly to-
gether to prevent their retraction, and thus
render the uninjured side the splint to that
which is fractured, giving it a continued support.
But as this plan makes the passage of the eva-
cuations difficult, and it does not press the frac-
tured portions firmly together, although it ren-
ders the length of the limbs equal, I adopt the
following plan :

The patient is to be placed on a mattress on
his back, the thigh is to be brought over a double
inclined plane composed of three boards, one be-
low which is to reach from the tuberosity of the
ischium to the patient’s heel, and the two others
above have a joint in the middle by which the
knee may be raised or depressed $ a few holes
should be made in the board admitting a peg
which prevents any change in the elevation
of the limb but that which the surgeon directs ;
over these a pillow is thrown to place the patient
in as easy a position as possible*. (See Plate.)

* The construction of this inclined plane is so little com-
plicated, that it may be made at the instant of two common
boards, one of which is to be sawn through nearly at the mid-
dle, and if hinges cannot be immediately procured, the boards
may be lashed together by cords ; for the principle of this
machine, I believe we are indebted to Mr. White, of Manches-
ter, who had one made of iron, and hollowed to adapt it to the
form of the leg and thigh, but this machine was too heavy and
too complicated for use. Mr. James, of Hoddesdon, improved

E upon

Treatment.

ON FRACTURES OF THE NECK OF

When the limb has been thus extended, a long
splint is to be placed upon the outer side of the
thigh to reach above the trochanter major, and
to the upper part of this is fixed a strong leather
strap which buckles around the pelvis, so as to
press the one portion of bone upon the other ;
and the lower part of the splint is to be fixed
with a strap around the knee to prevent its po-
sition being moved ; the limb must be kept as
steady as possible for eight weeks, at the end of

tipon Mr. White’s idea, by having the instrument made of
wood, with moveable splints upon the sides, which were to be
adapted to the limb, and this construction rendered it more
portable and less complicated than before ; but as the addition
of splints rendered the instrument less easy of adaptation, I
thought it better to have it made merely an inclined plane,
and to apply splints, or not, as occasion might require. I
have now been in the habit for near twenty years of employ-
ing this instrument in fractures of the thigh-bone, and also of
recommending it in my lectures, and do firmly believe that it
will be found the best means of keeping the limb constantly
extended, and preventing that contraction of muscles which is
so apt to occasion deformity. When the thigh and leg are
placed upon the machine, the patient rests upon his back, the
knee is slightly bent, and the foot rests upon the heel, and the
position is one of great ease to the patient. Although we are
ready to acknowledge the high merit of the contrivances of
Pessault and Boye for fractures of the thigh, yet upon the
whole we give a preference both to this instrument and to the
position which we have just described, and which we have
been in the habit of adopting in these eases. The same re-
sult may be produced by a long pillow reaching from the tu-
berosity of the ischium to the foot, and by a second rolled up
under the knee ; but the extension is neither so perfect at the
moment, or so continued as when the limb is on the inclined
plane, and it requires infinitely more care to prevent con-
traction. While I strongly recommend this double inclined
plane, I should think myself dishonest if I did not acknow-
ledge the source from which it was derived.

THE THIGH-BONE.

which time the patient may be permitted to rise
from his bed if the attempt does not give him
much pain ; he is still to retain his outer splint
for a fortnight, with the straps which I have
mentioned, round the pelvis, and by this treat-
ment he ultimately recovers a very good use of Recov
his limb. The following case shews the usual Case-
results of this accident when it is very severe.

Mr. Peggler, of Wanstead, aged 46, on the
13th of November, 1817, fell while walking, on a
glass bottle which he had in his pocket, and
when he attempted to raise himself from the
ground he found he was not able to stand. In
a quarter of an hour he felt great pain and could
not bear the slightest weight of his body on the
injured limb. Mr. Constable, of Woodford, was
sent for, and he gave me this account. The
foot at first did not appear to turn out, but when
the patient was put into bed and laid on his back
it became everted, the leg appeared somewhat
shorter, but was with but little difficulty pulled
down to its natural length ; the foot was be-
numbed, and continued so for twelve months.

He was placed in bed with a bolster under the
hip, to prevent displacement of the bone, and
his knees and ancles were tied together.

On the December following, about Christmas,

I met Mr. Constable to visit a patient with a
severe injury of the head, and he then requested
me to see Mr. Peggler, whom I found inca-
pable of turning in his bed without assistance,
and the attempt gave him great pain ; his in-
jured leg was a little shorter than the other,
with the trochanter drawn forwards towards the
spine of the ileum, and could be felt consider-

£2 ON FRACTURES OF THE NECK OF

ably separated from that portion of the trochan-
ter connected with the neck of the bone ; the
foot was turned outwards, he could not sit, and
the least attempt to raise himself produced ex-
cruciating suffering ; in the horizontal position
I brought him to the foot of the bed to make
as accurate an examination as I could of the
nature of the accident, and could have no hesi-
tation in pronouncing it a fracture through the
trochanter. In less than a month he began to
use his crutches, and continued their use for
three months ; he then laid aside one crutch
and employed a stick and crutch, and in a
short time needed the support of a stick only ;
but it was twelve months before he recovered
the entire use of his limb. The leg is still
nearly an inch shorter than the other ; the
portion of the trochanter connected with the
thigh-bone, has united with the fore part of
the trochanter joined to the neck of the bone,
and is consequently much nearer the spine of
the ilium than usual ; the foot also is slightly
everted, but he walks extremely well ; this day
week he walked ten miles from home and re-
turned the same day, and this day, July 28,
1819, he has walked from Wanstead to my
house, and intends to walk back, a distance of
near twenty miles.

This history of Mr. Peggler’s accident is so
similar to the cases of fracture through the tro-
chanter major, which I have had an opportu-
nity of seeing, that their detail would only be-
come a useless repetition, the only variations
that X have seen having been in the distinctness
of the crepitus accompanying them, which is

THE THIGH-BONE.

less in proportion as the fracture approaches the
capsular ligament.

I have received from Mr. Oldknow, of Not-
tingham, an account of some cases of the frac-
ture external to the ligament, which occurred
in persons very advanced in years, so that, as
age is not a certain criterion, it becomes neces^
sary to pay the utmost attention to the other dis-
criminating marks of this not unfrequent injury.

Of Fractures below the Trochanter .

The thigh-bone is sometimes broken just be-
low the trochanter major and minor, and a most
difficult accident it is to manage, and miserable
distortion the consequence, if it be ill treated.
The upper end of the bone is drawn forwards
and upwards, so as to form nearly a right angle
with the body of the thigh-bone; the cause of this
is evidently the contraction of the iliacus inter-
ims and psoas muscles, assisted perhaps by the
pectinalis and first head of the triceps, which
participate in the irritation the fracture pro-
duces, and are thrown into a state of spasmodic
contraction ; to give a better idea of this effect,
(see Plate) in which the bone will be observed
to be united not only with extreme shortening,
but with a hideous projection forwards. If
pressure be made upon the projecting bone in
this case, it only adds to the patient’s suffering,
and to the degree of irritation of the limb, with-
out preserving the bone in its proper situation.
It will be seen that this fracture, although unit-
ing, exceedingly overlaps, and that the union
is very feeble, shewing what I have already

ON DISLOCATIONS

mentioned, the circumstance of fracture thus
placed having the ossific deposition only on that
side where the inflammation was kept up by the
pressure of one bone lying on the other ; this
preparation may be seen at the Anatomical Mu-
seum at St. Thomas’s Hospital.

To prevent this horrid distortion and imper-
fect union, two principles are required to be
strictly observed \ the one is to elevate the knee
very much over the double inclined plane, and
the other to place the patient in a sitting posi-
tion, well supporting him by pillows during the
progress of its union \ the degree of elevation
of the body which is required will be readily as-
certained by observing the approximation of the
fractured extremities of the bones $ and this po-
sition is demanded, to relax the psoas and ilia-
cus muscles, and thus prevent the elevation of
the upper part of the bone. In this way, and
thus only, can the great deformity I have de-
scribed be prevented. When by this posture
the extremities of the bones are brought into
proper apposition, and all projection of its up-
per portion is removed, either the splints may
be applied which are commonly used in fracture
of the thigh-bone, or, what is better, a strong
leather belt lined with some soft material, should
by means of several straps be buckled around
the limb.

OF DISLOCATION OF THE KNEE.

The broad surfaces of bone by which the os
femoris rests upon the tibia are calculated to

OF THE KNEE.

prevent the ready dislocation of this joint, which
would be otherwise very liable to happen, from
the superficial nature of the articulating cavities
on the head of the tibia, and also from the
great violence to which this joint is frequently
exposed.

The depressions upon the head of the tibia
are however rendered deeper by the addition of
the semi-lunar cartilages which rest upon the
bone, they receive the condyles of the os fe-
moris, and are attached by ligaments to the
edge of the tibia. The fore part of the joint is
defended by the patella, which has two unequal
articular surfaces to play upon the condyles of
the os femoris ; the head of the fibula forms no
part of the knee-joint, but is attached with the
tibia from an half to three-fourths of an inch be-
low its head.

The junction of the os femoris, tibia and pa-
tella, is produced by means of a capsular liga-
ment, which proceeds from the os femoris to the
head of the tibia, and is attached to the edge
of the patella where it divides into two portions,
forms wings to that bone, and takes the name
of alar ligaments. On its outer side the capsu-
lar ligament is covered and greatly strengthened
by the tendinous expansions which are derived
from the vasti muscles, arid which proceed to
the head of the tibia. Internally the ligament
is lined by the synovial membrane, which is
folded within the cavities on the extremities of
the bones, and is reflected from the ligament to
the edge of the articular cartilages, and it is
believed forms a covering to the articular earth

Structure
of the
knee.

Bone,

Ligaments.

ON DISLOCATIONS

lages, Beside the capsular there are several
peculiar ligaments. First , the ligamentum pa-
tellae, which is stretched from the lower part of
the patella to the tubercle of the tibia. Secondly ,
the external lateral or femoro fibular ligament,
which passes from the os femoris to the head
of the fibula, and which divides into two
external lateral ligaments. Thirdly , the inter-
nal lateral or femoro tibial ligament being at-
tached to the os femoris, and to the head of the
tibia. Fourthly , the oblique or popliteal liga-
ment, which proceeds from the external condyle
of the os femoris obliquely to be inserted into
the head of the tibia. Fifthly , the crucial liga-
ments which pass from the depression between
the condyles of the os femoris behind ; the one
to a projection between the articular surfaces of
the head of the tibia, and the other to a de-
pression behind that projection, so that these
ligaments cross each other from before back-
wards. The patella has a muscular connection
with the os femoris by the insertion of the rec-
tus, vasti, and cruralis, and by the ligamentum
patellae it is united with the tibia, and laterally
it is joined to the capsular and alar ligaments.
This ligamentous junction of the three bones is
very firm, but it allows of free flexion and ex-
tension with some degree of rotatory motion
when the knee is bent ; but although great
strength of union is produced of the joint, still
excessive violence and extreme relaxation will
occasionally lead to its dislocation.

OF THE KNEE.

On Dislocations of the Patella .

The patella is liable to be dislocated in three Tire!

c 1 directions.

directions ; namely, outwards, inwards, and
upwards. In its lateral dislocation the bone is Symptoms,
most frequently thrown on the external condyle
of the os femoris, where it produces a great pro-
jection ; and this circumstance, with an inca-
pacity of bending the knee, is the strong evi-
dence of the nature of the injury.

The most frequent cause of the accident is Cause,
from a person, in walking or running, falling
with his knee turned inwards, and the foot out-
wards, and thus, by the action of the muscles
to prevent the fall, the patella is drawn over the
external condyle of the os femoris, and when the
person attempts to rise, he finds himself unable
to bend his leg, and the muscles and ligaments
of the patella are all forcibly on the stretch.

This accident generally occurs in those who
have some inclination of the knee inwards,
which, under the action of the extensor muscles,
gives a direction to the patella outwards. — The
internal dislocation is much less frequent, and it internal,
happens from falls upon a projecting body, by
which the patella is struck upon its outer side,
or by the foot being, at the time of the fall,
turned inwards.

What the state of the ligament in these cases

is, I have had no opportunity of learning, having
never dissected a limb in which this accident had
happened.

The inode of reduction in either case con-

Mode of
reduction.

ON DISLOCATIONS

sists in pursuing the following plan. The pa-
tient is placed in a recumbent posture, and an
assistant raises the leg by lifting it at the heel ;
the advantage of which is, that it extends the
limb in the greatest possible degree ; then the
surgeon presses down that edge of the patella
which is most remote from the joint, be it one
luxation or the other ; and this pressure raises
the inner edge of the bone over the condyle of
the os femoris, and it is immediately drawn,
by the force of the muscles, into its situation.

My friend, Mr. George Young, informed me,
that he was called to a case of dislocation of the
patella outwards, in which the reduction of the
patella was very difficult. The patient was a
female, who, by a fall in walking, had the patella
drawn over the external condyle of the os fe-
moris, where it remained. He employed, most
perseveringly, pressure upon the edge of the
patella, without being able to succeed, but at
last reduced it in the following manner. He
placed the patient’s ancle upon his shoulder,
and thus most completely extended the limb,
and obtained a fixed point of resistance at the
knee. Then grasping the patella with the
fingers of his right hand, he pressed the outei4
edge of the patella with the ball of his left thumb
and pushed it into its place.

An evaporating lotion of spirits of wine and
water is to be applied, and in two or three days
the limb may be bandaged, and it is soon re-
stored to its natural uses, although it is some-
what weaker than before.

When the botie is dislocated from relaxa*

Dislocation
from re-
laxation.

OF THE KNEE.

tion, (See First Part of these Essays) the patella
is drawn upon the external condyle of the os
femoris from very slight accidents, or from sud-
den action of the muscles. My neighbour, Mr.
Hutchinson, who has seen a great deal of sur-
gery, informs me, he has very frequently seen
this accident, and that the tendency to it has
arisen, in a large proportion of cases, from the
relaxation produced by excessive indulgence in
onanism.

The reduction, in these cases, is effected in
the same manner as has been before described.

After the reduction, to prevent any recurrence
of the accident, and to support the weakened
ligament, a laced knee cap, with a strap and
buckle above and below the patella is to be worn.

On the Dislocation of the Patella upwards.

In this dislocation the ligament of the patella Upwards,
is torn through by the action of the rectus fe- i dgament
moris muscle, and the immediate effect of the lacc,ated'
injury is to draw the patella upwards upon the
fore part of the thigh-bone. — The appearances symptoms
which this accident presents, are very decisive
of the nature of the injury; for, besides the ele-
vation of the patella, and its easy motion from
side to side, a deep depression is felt above the
tubercle of the tibia from the absence of the
ligament : the patient immediately loses the
power of bearing upon that limb, as the knee
bends under each attempt, and he would fall if
he persisted in throwing the weight of his body
upon it. A considerable degree of inflamma-
tion follows.

ON DISLOCATIONS

Treatment.

Four

directions.

Local depletion and evaporating lotions are
to be used for from four to seven days, and
then a roller is to be applied around the foot
and upon the leg, to prevent it from swell-
ing, the leg is to be kept extended by a splint
behind the knee, and a bandage composed of
a leather strap is to be buckled around the
lower part of the thigh ; to this is to be at-
tached another, which is to be carried on each
side of the leg, and under the foot, and is to
be buckled to the circular strap ; thus the bone
is gradually drawn down, so as to allow of
an union of the ligament. In a month the knee
may be slightly bent, and as much passive mo-
tion daily given as the patient is able to bear ;
by these means the ruptured ligament becomes
united, and the patella retains its motion. With
very great attention this becomes perfect : for
so it happened in a case which I saw with Mr.
Burrowes, in Bishopsgate Street. Mr. B. paid
great attention to the case, and the patient re-
covered without any diminution of the natural
powers of the part, the patella being gradually
drawn down, until the ends of the ligament
were approximated and coalesced.

On dislocation of the Tibia at the Knee-Joint

These dislocations occur in four different
directions ; but two of them are incomplete and
lateral, while the others are perfect luxations,
the tibia being thrown either backwards or for-
wards.

The lateral dislocations are but rare. In the

OF THE KNEE.

dislocation inwards, the tibia is thrown from its internal,
situation, so that the condyle of the os femoris
rests upon the external semilunar cartilage, and
the tibia projects much on the inner side of the
joint, so as at once to disclose the nature of the
injury. The first case of this kind which I ever
witnessed was brought to St. Thomas’s Hos-
pital whilst X was apprentice there ; and X re-
member being struck with three circumstances
in the case : the first was the great deformity of
the knee from the projection of the tibia ;
secondly, the ease with which the bone was
reduced by direct extension ; and, thirdly, the
little inflammation which followed upon what
appeared to be so serious an injury; for the man
was discharged from the hospital, having suffered
little local or constitutional irritation.

The tibia is now and then thrown upon the External,
outer side of the knee-joint, the condyle of the
os femoris being placed in the situation of the
inner semilunar cartilage, or rather behind it,
when an equal deformity is produced, as in the
other dislocation. The reduction of the limb
is equally easy with the former, and the pa-
tient recovers with little diminution of the
powers of the part. Xt seems to me, that in both
these dislocations the tibia is rather twisted upon
the os femoris, so that the condyle of the os
femoris, with respect to the tibia, is thrown
somewhat backwards, as well as outwards or
inwards.

CASE.

One of the aldermen of the city of London, case.

ON DISLOCATIONS

Case of

dislocation

inwards.

riding down High gate-hill during the night, and
not being aware of a rail being placed across a
part of the road which was repairing, the horse
ran against the rail, and turning quickly, threw
his rider over the rail, whilst his leg was confined
between it and the horse, so that his body was on
one side of the rail, and his leg on the other :
the result of this was, that he partially dislocated
his tibia outwards, throwing the condyle of the
os femoris inwards. Being immediately taken
to a public-house, the tibia was easily replaced,
and being, some hours after, taken home, means
were used to reduce the swelling and inflamma-
tion which in him became considerable. When
he attempted to bear upon the limb he found
the capsular ligament very feeble, and he was
obliged to have a knee-cap made of very strong
leather to support and connect the bones ; and
by the aid of this bandage he gradually reco-
vered, and was enabled to walk well and to do
duty on horseback, as a light horse volunteer,
before twelve months had expired.

CASE.

I was consulted by Mr. Richards respecting
Mr. Bovill, a gentleman from Barbadoes, who
had dislocated his knee. I made a few notes on
the case at the moment, which were as follow.
The gentleman was thrown from a gig ; the tibia
was dislocated, and the fibula broken a little be-
low its head. The head of the tibia projected
much on the inner side of the condyle of the os
femoris. My friends, Mr. Caddell and Mr.

OF THE KNEE.

Richards, surgeons in Barbadoes, saw him in a
quarter of an hour after the accident ; the leg was
extended from the thigh-bone, in a bent position
of the limb ; the extension was a long time con-
tinued, and the force was employed by several
persons for half an hour before the luxation was
reduced. It became excessively swollen, and re-
mained so for many weeks, the climate probably
being unfavourable to his recovery; but at length
the inflammation and its consequences were
overcome by local depletion. When I saw him,
eighteen months had elapsed from the accident,
and he could not then bend the joint at right
angles with the thigh ; there was also an unna-
tural lateral motion of the joint, from the in-
jury which the ligaments had sustained. The
fracture of the fibula had injured the peroneal
nerve, as was evident from the numbness of which
he complained in the course of its distribution.

The tibia is now and then dislocated in the
direction forwards. In this accident, when the
person is recumbent, the external marks of the
injury are these. The tibia is elevated, the
thigh-bone is depressed, and is thrown some-
what to the side as well as backwards. The
os femoris makes such pressure on the popli-
teal artery, as to prevent the pulsation of
the anterior tibial artery on the* foot ; the pa-
tella and tibia are drawn by the rectus muscle
forwards. Such were the appearances in a man
of the name of Briggs, brought into Guy’s
Hospital in the year 1 802, not only with this
accident, but with a compound fracture of the
tibia of the other leg, with dislocation of the
head of the fibula. Mr. Lucas was obliged to

Dislocation
of the tibia
forwards.

ON DISLOCATIONS

Dislocation
of t he tibia
backwards.

Case by Dr.
Walsh man.

amputate the compound fracture, and the man
is now living at Walworth. The limb in this
case was easily reduced, by extending the thigh
from above the knee, and by drawing the leg
from the thigh and inclining the tibia a little
downwards. Directly as it was reduced the
popliteal artery ceasing to be compressed, the
pulsation in the anterior tibia! was restored.
The head of the tibia is sometimes dislocated
backwards, behind the condyles of the os fe-
moris, producing the following appearances :
a shortened state of the limb, a projection of
the condyles of the os femoris, and depression
at the ligament of the patella, and the leg is bent
forwards. The following case, for which I am
indebted to my friend Dr. Walshman, who has
ever been a man of close observation in his
profession, and always practised it with atten-
tion, judgment, and with honor.

CASE.

Mr. Luland, residing near the Elephant and
Castle, at Newington Butts, a very robust and
muscular man, on the 4th of January, 1796,
dislocated his shoulder and knee at the same
instant. The accident happened in the follow-
ing manner : it being a very severe frost, and
the ground very slippery, he being in his cart,
the horse fell. Mr. Luland was thrown under
the front rail of the cart and luxated the tibia
backwards, whilst his shoulder fell on the saddle
and dislocated the os humeri into the axilla.
The head of the tibia was completely dislocated
backwards, reaching behind the condyles of

OF THE KNEE.

ilie femur into the ham; the tendinous connec-
tion of the patella to the rectus muscle was
ruptured ; the external condyle of the os fe-
moris very protuberant, the leg shorter, and
there was a depression just above the patella.

The patient felt most excruciating pain when c^e.
the limb was moved, but there was not any
considerable degree of suffering when it was
at rest. The reduction was effected in the
following manner : two men extended the limb
upwards, one from the groin and the other
from the axilla, whilst two others extended
the leg from a little above the ancle in the
opposite direction; and they gradually increased
the force of their extension till the bone was
reduced. The patient was placed on his back,
and Dr. Walshman directed the head of the
bone to its natural situation. Dr. W. then ap-
plied a flannel roller on the knee, placed the
patient in bed with his limb upon a pillow, and
directed the part to be kept wet with an eva-
porating lotion. He remained in this state a
fortnight, free from pain; the Dr. slightly moved
the part every other day, as far as he could
without giving pain. In about a month Mr.
Luland began to walk on crutches. Ten weeks
after the accident he was able to sit at his
dinner-table, and in five months he had given
up the use of his crutches, and appeared per-
fectly recovered, being able to use that limb as
well as the other. He died of dropsy, February
18, 1819.

Dr. Walshman’s treatment of this case was
highly judicious. He suffered the parts, as he
observes in his letter, to remain at rest till the

ON DISLOCATIONS

From re-
laxation.

Mr Hey’s
idea.

adhesive inflammation had united the lacerated
ligament, and then, and not till then, began with
passive motion.

On partial Luxations of the Thigh-hone from
the Semilunar Cartilages •

Under extreme degrees of relaxation, or in
cases where there has been an increased secre-
tion into a joint, the ligaments become so much
lengthened as to allow the cartilages to glide
upon the surface of the tibia, and particularly
when pressure is made by the thigh-bone on the
edge of the cartilage. That excellent practical
surgeon, Mr. Hey, of Leeds, whose death will
be severely deplored in the district in which he
practised, and lamented by those in the profes-
sion who have its improvement at heart, was
the flrst who clearly described the symptoms and
cause of these accidents, and suggested a mode
of treatment, which is ingenious, scientific, and
generally successful. The most frequent cause
of the accident is from a person in walking
striking his toe when the foot is everted against
any projection (as the fold of a carpet), he im-
mediately feels pain in the knee, which is un-
able to be completely extended. I have known
this accident also happen from a person having
suddenly turned in his bed, and the clothes not
suffering the foot readily to turn with the
body, the thigh-bone has slipped from its semi-
lunar cartilage. I have also known it occur
from a sudden twist of the knee inwards when
the foot was turned out.

The explanation of this accident is as follows:

OF THE KNEE.

The semilunar cartilages which receive the con-
dyles of the os femoris are united to the tibia by
ligaments, and when these ligaments become ex-
tremely relaxed and elongated, the cartilages are
easily pushed from their situation by the condyles
of the os femoris, which are then brought into
contact with the head of the tibia, and when the
limb is attempted to be extended the edges of the
semilunar cartilages prevent it. How then is the
bone to be again brought upon the cartilages ?
Why, as Mr. Hey has advised, by bending the
limb back as far as is possible, which enables
the cartilage to slip into its natural situation,
from the pressure of the thigh-bone being re-
moved in the bent position, and the leg being
brought forwards it can then be completely ex-
tended, because the condyles of the os femoris
are again received on the semilunar cartilages.
This plan is not however invariably success-
ful, as the following case will shew. A lieu-
tenant in the army had this accident repeat-
edly happen to him, and the limb was as often
reduced by the above means; but at length in
turning in bed, from the pressure of the bed-
clothes on his foot, the accident recurred. He
came to town; but bending the limb had now no
effect in enabling him to extend the joint, I
therefore advised him to visit Mr. Hey at Leeds;
but I learnt that in this case the joint was never
reduced. I also made the following notes of the
case of a gentleman who came to my house.

Mr. Henry Dobley, ast. 37, has often dislocated
his knee by turning the foot inwards and the
thigh-bone outwards, by accidentally slipping
in walking on uneven ground, or under sudden

Explana-
tion of the
accident*

Mode of
i eduction.

Sometimes

unsuccess-

ful.

ON DISLOCATIONS

Different
mode of re-
duction.

Particular
bandage re-
quired.

Case.

exertions of the limb \ considerable pain is im-
mediately produced, accompanied with a great
deal of swelling. His mode of reducing it is
as follows : he sits upon the ground, and then
bending the thigh inwards and pulling the foot
outwards, the subluxation of the os femoris
being external, the natural position of the limb
becomes restored. A knee-cap laced tightly
around the knee is the usual preventive of the
return of this accident, but it is not sufficient in
Mr. Dobley, without the addition of straps, and
more especially of a very strong leather one just
below the patella.”

A young lady was brought to my house who
was frequently the subject of this accident, but
in her the cartilages had beqti several times
easily replaced, and the return of the accident
prevented by a bandage composed of a piece
of linen with four rollers attached to it, (see
Plate,) which were tightly bound above and be-
low the patella, and she said, answered its in-
tended purpose better than any other.

Great alteration takes place in the form and
size of the knees, in some of these cases, from
a chronic rheumatism sometimes attending
them. I made the following notes of a case of
this kind, about which I was consulted, but I
have seen several similar to it.

CASE.

Lady D — — , a year and a half ago fell and
twisted her thigh-bone inwards at the knee,
producing great pain on the inner side of the
joint. Her ladyship immediately restored the

OF THE KNEE*

parts to their situation, by pressing the thigh
outwards and the leg inwards, previous to which
she could not move the joint. For a fortnight
she was scarcely able to betid or straighten the
knee, and the muscles felt to her to be in a
state of cramp. She then began to stand upon
the limb by the aid of crutches, but when she
bore upon it considerably it suddenly bent
back, with pain and subsequent swelling, and
she felt the condyles at the time slip from the
semilunar cartilages upon the head of the tibia.
Any sudden motion produced the same effect
for fifteen months, and each of these accidents
threw her back for several weeks; the pain ex-
tended from the knee to the toe. For three
months previous to her last accident she walked
on crutches, and even at times with only the
aid of a stick; when about two months since,
in endeavouring to raise herself from a sofa,
and turning quickly round to take her stick,
the left knee gave way, as if the bone had
slipped from its place, the thigh-bone being at
the time twisted outwards ; pain and swelling
succeeded, and she has never been able to
stand upright since. Her joints are all of them
remarkably flexible, as the elbow may be easily
bent backwards to form an angle with the os
humeri. When a girl she had frequently the
sensation of putting the knees out of joint,
but they soon got well. The knees are now
swollen, and effusion has taken place into the
joints of a considerable quantity of synovia.
When she attempts to stand she cannot straighten
her knees, but would fall forwards if not sup-
ported. The principal treatment is to produce

ON DISLOCATIONS

absorption of the fluid which is effused, and
then to give due support to the ligaments.
For the first of these she was desired to apply
blisters, which were directed to be kept dis-
charging for a considerable time, and after they
were healed she was ordered to make pressure
upon the joints by a strong bandage, which was
to be occasionally removed to give an oppor-
tunity of employing friction.

In the dissection of these cases the ligament

* ■ - .■ * +'

is found extremely thickened ; little pendulous
ligamentous and cartilaginous bodies are seen
suspended from it, a thick edge of cartilage
projects from that of the articular cartilage, and
a part of the latter is absorbed. When the bone
is macerated, a great addition of ossific matter is
found to have been made to the edges of the
condyles of the os femoris.

On Compound Dislocations of the Knee-joint .

| f v * ' - ‘

Of this I have only seen one instance, and I
conclude it to be therefore a rare occurrence 5
and there are scarcely any accidents to which
the body is liable which more imperiously de~
mand immediate amputation than these.

CASE.

On Monday, August 26th, 1819, at eleven
p. m. I was sent for by Mr. Oliver, surgeon at
Brentford, to visit Mr. Pritt, who I was in?
formed had fallen from the box of a mail-coach,
and most severely injured his knee. I met, at
the house to which he was carried, Mr. Oliver

OF THE KNEE*

and Mr. Hunter of Richmond, surgeons, and
immediately proceeded to examine the knee.
A large opening was found in the integuments,
through which the external condyle of the os
femoris projected, so as to be opposite the
edges of the skin. The os femoris was thrown
behind the tibia on its outer side, but not so
much on the inner, so that the external con-
dyle of the thigh-bone was dislocated back-
wards and outwards; and the axis of the thigh-
bone was twisted, and the internal condyle ad-
vanced upon the head of the tibia. We made
attempts to reduce the condyle, but it could
only be effected with extreme difficulty; and
the bone, directly the extension was removed,
slipped into its former situation. The joint
being freely opened by the accident the bone
dislocated, and when reduced easily slipping
from its place, accompanied with an extremely
irritable constitution, decided me at once to
propose the amputation of the limb, which
being acceded to, it was immediately per-
formed. The symptoms of constitutional irrita-
tion which followed the operation became ex-
tremely severe, and he being delirious on the
31st, Mr. Oliver applied leeches to his tem-
ples, a blister under the occiput, and gave the
saline medicine with camphor and the pulv*
ipec. comp. On the following day I was sent
for to visit him, but being absent from London,
my most able and excellent friend Mr. Cline,
senior, visited him, and ordered him.

Tine. Opii. gtt. v®

Pulv. Castor, gr. x.

Mist. Camphor, yiss. M.

Ft. Haustus 4ta quaque hora su-mendus*

ON DISLOCATIONS

Soon after the second draught was administered
he fell asleep, and after several hours’ repose he
awoke perfectly sensible. He gradually reco-
vered, and left Brentford on the 25th of Octo-
ber, with a small wound still remaining: on the
stump.

Dissection. I brought home the limb and carefully dis-
sected it. Under the skin there was great ex-
travasation of blood in the cellular membrane
surrounding the knee; the vastus internus mus-
cle had a large aperture torn in it, just above
its insertion into the patella; the tibia projected
forwards and the patella was drawn to the outer
side of the knee, being no longer in a line with
the tubercle of the tibia. Looking at the joint
posteriorly, both heads of the gastrocnemius
externus muscle were lacerated ; the capsular
ligament was so completely tom posteriorly that
both the condyles of the os femoris were seen
projecting through the laceration in the gas-
trocnemius; neither the sciatic nerve, the pop-
liteal artery and vein, the lateral nor the crucial
ligaments were ruptured. (See Plate.)

It is probable that all compound dislocations
of the knee-joint will require a similar practice,
unless the wound be so extremely small as to
admit readily of its immediate closure.

On Dislocation of the Knee from Ulceration.

In the progress of chronic diseases of the
joints, inflammation beginning in the synovial
membrane and proceeding to ulcerate the arti-
cular cartilages and bone, at length affect the
Ligaments capsular ligament and even sometimes the pe-
culiar ligaments of the joints; the bones are

OF THE KNEE.

thus becoming unconnected, the muscles irri-
tat edby participating in the inflammation draw
the limb into distorted positions, and thus one
bone becomes gradually displaced from the
other. In the hip -joint this is most frequently
seen from the oblique bearing of the thigh-bone
on the pelvis. In the knee it is also not unu-
sual that the thigh-bone shall be placed out of
its natural line with the tibia, projecting either
on the one side or upon the other ; but now
and then most remarkable distortions are pro-
duced by the irritative and spasmodic action of
the muscles succeeding the ulcerative process
of the ligaments, of one of which I have given
a plate ; it was removed by amputation by Mr.
Cline, sen. in St. Thomas’s Hospital, and had
been the consequence of what is vulgarly called
the white swelling of the knee-joint ; the leg
was placed forwards at right angles with the
thigh, so that when walking on his crutches he
had the most grotesque appearance, as the bot-
tom of his foot first met the eye when he was
advancing. Upon inspection of the patella it
was found anchylosed to the os femoris, and the
tibia was also joined by ossific union to the fore
part of the condyles of the thigh-bone.

This state of parts may be prevented by op-
posing the action of the muscles when their
irritability first begins to produce distortion, by
the application of splints, and by the exhibition
of opium to diminish the irritability of the
system. Thus I have seen in cases of ulcera-
tion of the hip-joint, the irritative action of the
flexor muscles diminished, and the distortion
prevented by drawing down the limb and keep-

Excessive

distortion.

Case.

How pre-:
vented.

ON FRACTURES

Transverse

or longi-
tudinal.

Symptoms.

ing it in the extended position, but it is a most
painful extension to the patient, and should be
very gradually accomplished.

On Fractures of the Knee-joint*

I shall now, pursuing my former plan, de-
scribe the fractures to which the bones entering
into the composition of this part are liable, and
first the

Fractures of the Fatetta.

This bone is generally broken transversely,
but sometimes, though rarely, longitudinally*
It is liable also to simple and compound fracture,
but fortunately the latter is but of rare occur-
rence.

When the patella is transversely broken, the
upper part of the bone is drawn from the lower,
its superior portion of the bone being elevated
by the action of the rectus muscle, which is
inserted into its upper part, whilst the lower
portion is still retained in its natural situation
by the ligament of the membrane which passes
to the tubercle of the tibia.

The degree of separation thus produced de-
pends on the extent of laceration of the liga-
ment, for when the ligament is but little torn
the separation will be half an inch, but under
great extent of injury the bone is drawn five
inches upwards ; the capsular ligament and ten-
dinous aponeurosis covering it, being then
greatly lacerated ; and this is the greatest ex-
tent of separation which I have seen. The acci-

OF THE KNEE.

dent may be at once known by the depression
between the two portions of bone, and by the
fingers passing readily down to the condyles of
the os femoris into the joint as far as the in-
teguments will permit, and by the elevated por-
tion of bone moving readily on the lower and
fore part of the thigh. The power of ex ten d-
ing the limb is lost, and likewise that of sup-
porting the weight of the body on that limb if
the person be standing, for the knee bends for-
wards from the loss of action in the extensor
muscles. The pain of this accident is not very
severe, and a simple fracture is not dangerous, for
the constitution feels it but little. In a very few
hours after the accident has occurred, a consider-
able degree of extravasation of blood takes place
upon the fore part of the joint, so that the appear-
ance is livid, having often a gangrenous charac-
ter, but this disappears in a few days. Consi-
derable inflammation and fever succeed, an^l
more especially there is a great degree of swel-
ling in the fore part of the joint, both from the
free secretion of synovia, and the effusion
arising from inflammation. No crepitus is felt
in this fracture, for the bones cannot be brought
sufficiently near each other to give this general
discriminating mark of other fractures.

The separation of the bones is much in-
creased by bending the knee, as it removes the
lower from the upper portion of bone, pulling
down the tibia^ligamentuny; patellm, and lower
part of the bone from the upper.

This accident arises from two causes : first, Causes,
from blows upon the bone produced by falls
open the knee, or received upon the patella in

ON FRACTURES

Flows or
action of
rouscles.

Explana-
tion of ft„

Mode of
pnion.

the erect position of the body ; and secondly ,
from the action of the extensor muscles upon
the bone.

A gentleman walking in the country, and
not used to jumping, leaped a ditch of consi-
derable breadth ; and when he reached the op-
posite bank he was in danger of falling and ran
forward several steps, and with difficulty reco-
vered himself. Whilst in this attempt to save
himself from a fall, he felt the patella snap,
and I was sent for to him, and found his pa-
tella broken, and the portions of bone consi-
derably separated.

A lady, descending some stairs, set her heel
near the edge of one of the stairs, and was in
danger of falling, when throwing her body
somewhat backwards to prevent the fall and to
straighten the knee, the patella became broken.

That a bone should thus break by the action
of muscles appears at first sight incomprehensi-
ble, but the solution of this circumstance is easily
given. When the knee is bent, the patella is
drawn down on the end of the condyles, so as to
bring the upper edge of the bone forwards, and
at that moment it is the patella is broken, by
the rectus muscle not acting in a line with the
bone but at right angles with it or nearly so,
and upon its upper edge more particularly.

With respect to the mode of union of this
bone, whether the separation be great or inconsi-
derable, it is effected by an intervening ligamen-
tous substance. The bone itself undergoes but
little alteration ; the lower portion, joined by
ligament to the patella,, has its broken cancel-
lated structure still apparent, although a little

OF THE KNEE.

smoothed. The upper portion of bone has its
broken cancelli covered by a slight ossific de-
posit, so that there is more ossific action in the
upper than in the lower portion of the bone,
and certainly much less than in bones which do
not form a part of the joints. The internal
articular surface of the bone preserves its na-
tural smoothness. Blood is immediately depo-
sited in the place of the injured ligament, but
this in a few days is absorbed. Inflammation
arises and pours out adhesive matter, which
extends from one edge of the lacerated liga-
ment to the other, and even between the bones,
to each of which it is firmly united. (See Plate.)
Vessels shoot from the edges of the ligament and
render the new substance organized, and pro-
duce a ligamentous structure similar to that from
which the vessels shoot ; this substance is not
however always perfect, for I have seen aper-
tures in it ; but this will greatly depend upon
the extent of the laceration of the ligament, and
the too early use of the limb. In the dog and
in the rabbit, or almost any other quadruped, it
is possible by experiment to trace the mode of
union of this bone.

EXPERIMENT I.

I drew the integuments much aside in a rab-
bit, and dividing them, placed a knife upon
the patella and struck it lightly with a mallet;
the bone was broken and directly drawn up.
I let the integuments go, and the wound was
not opposite the fracture. In forty-eight hours
I killed the animal and examined the part.

ON FRACTURES

The bones were separated three-quarters of atl
inch, and the intervening part filled with coa-
gulated blood.

EXPERIMENT II.

I repeated the former experiment, and killed
the animal on the eighth day, and found most
of the blood absorbed and adhesive matter oc-
cupying the space between the bones.

experiment III.

The former experiment repeated ; the ani-
mal examined on the fifteenth day. The adhe*
sive matter had acquired a smooth and some-
what ligamentous character.

EXPERIMENT IV.

The same division of the bone being made, it
was examined on the twenty-second day, when
the new ligament was complete.

EXPERIMENT V.

The same repeated in five weeks. The part
was injected, and vessels were found proceed-
ing from the edge of the ligament into the
adhesive matter, now become ligamentous. So
that at the end of five weeks the vascularity
is complete, and some vessels proceed from the
bone and find the ligament. Upon the dog
these processes may be equally well observed,

OF THE KNEE. 79

but they are not quite so rapidly produced in a
large dog as in the rabbit.

The parts were dissected and preserved after
these experiments both in the dog and rabbit,
and I have them in the collection at St. Thomas’s
Hospital, where they may be always seen.

EXPERIMENT VI.

In a rabbit, having divided the bone, I sewed
together the two portions by conveying a needle
and thread through the tendinous covering of
the bone, but the ligatures separated, and the
bones still united by ligament.

EXPERIMENT VII.

I divided the bone, and cut the rectus muscle
through, yet the patella united by ligament.

I could not either in the dog or in the rabbit
succeed in producing a bony union in the trans-
verse fracture.

Yet I once saw in a patient of my kind
friend, M. Chopart, at Paris, a case which ap-
peared to me to be united by bone, the separa-
tion was so small, but I should now suppose I
was mistaken.

A ligamentous union of the transverse fracture
of the patella is, then, probably that which con-
stantly occurs ; or if there be an exception, it is
very rare. But still the principle which is to guide Ligament-
the surgeon’s conduct is, to make that ligament as short as
as short as possible. If the ligament be of great IS possibIe’
length, there is a proportionate weakness ; for as
soon as the accident has happened, the rec-
tus muscle retracts and draws up the bone,
and in proportion to the retraction suffered

ON FRACTURES

Treatment.

to remain, is the degree of shortening of the
muscle, and consequently the diminution of
its power. Those, therefore, who have had the
bones widely separated, when they walk quickly,
do it with a halt, and are very liable to fall, and
to break the other patella. Let then f,he muscle
be brought as nearly as it can be into its natural
length, and although complete apposition of the
bone is very rarely effected, yet the ligamentous
union is rendered as short as circumstances will
permit, and the patient will recover the entire
use of the limb.

The idea which was formerly entertained of the
danger of squeezing the callus into a projection
in the inner side of the bone so as to destroy the
smoothness of its internal surface is not at all
tenable.

When called to this accident the surgeon
places the patient in bed upon a mattress, ex-
tends the limb upon a well padded splint placed
behind the thigh and leg, to which it is tied,
and which splint should be hollowed. An eva-
porating lotion is then applied upon the knee
consisting of Liq. Plumbi s . acetat. dibit. 5. v.
with Spir. Vini 5. i. ; and no bandage should
be at first employed. The body should be slightly
raised in bed to relax the rectus muscle, and
the heel should be raised to bring up the lower
portion of the patella. If, on the succeeding
day or two, there be much tension or ecchymosis,
leeches should be applied, and the lotion should
be continued ; when, after a few days, the ten-
sion has subsided, then, and not till then, should
bandages be employed. I have seen the greatest
suffering and swelling produced by the early
application of bandages in these cases, even so

OF THE KNEE.

as to threaten sloughing of the skin when there
had been much contusion. The means which
are most frequently employed in the treatment
of this case are as follow. A roller is applied
from the foot to the knee, to prevent the swelb
ing of the leg, and the upper portion of bone
is pressed downwards as far as it can be with-
out violence, towards the lower, so as to les-
sen the retraction of the muscles and produce the
approximation of the portions of bone. Then
rollers are applied above and below the joint,
confining a piece of broad tape next the skin
on each side, which crosses the rollers at right
angles; these portions of tape are bent down and
tied over the rollers so as to brine; them near each
other, and thus to keep down the upper por-
tion of bone. Sometimes, instead of the tape
on each side, a broad piece of linen is bent over
the rollers on the fore part of the joint, and is
there confined so as to approximate the pieces
of bone, and to bind down the upper portion of
the patella, that its lower broken edge may not
turn forwards.

But the mode I prefer is as follows: A leather
strap is buckled around the thigh, above the
broken and elevated portion of bone,andfrom this
circular piece of leather, another strap is passed
under the middle of the foot, the leg being ex-
tended, and the foot raised as much as possible.
This strap is brought upon each side of the leg,
and buckled to that which is fixed around the
lower part of the thigh. The strap may be
confined to the foot by a tape tied to it, and
to the leg at any part in the same manner ; and

ON FRACTURES

State of the
muscle.

this is the most convenient bandage for the
fractured patella and for the patella dislocated
upwards by the tear of its ligament.

In this position, and thus confined, the limb
is to be kept for five weeks in the adult, and for
six weeks at a more advanced age.

Then a slight passive motion is to be begun,
and this must be done gently and with so much
circumspection, that the ligament, if not firmly
united, shall not give way, and the bones recede.
If the union be found sufficiently firm to bear it,
the passive motion is to be employed from day
to day until the flexion of the limb be com*
plete.

If passive motion be not used, it appears that
the action of the extensor muscles would never
return ; for those who are kept in bed, with the
joint at rest, do not in many months acquire
any power of bending and extending the limb ;
but when passive motion has been used, the
patient is placed on a high seat and directed to
swing the leg, by which motion is given to the
rectus, and if the mind be then directed to the
contraction of that muscle, its powers will be
gradually renewed. When the rectus muscle has
been shortened, and the upper portion of bone
is drawn from the lower, all the disposition to
action in that muscle ceases $ and it does not
seem disposed to recover its voluntary action
until it becomes again elongated, which is
effected after the union of the ligament, by
bending the knee ; and from this point of elon-
gation the muscle begins to contract.

A young woman was brought into my house

OF THE KNEE.

in her father’s arms, and he said, u X am
obliged to carry her, for she has lost the use
of her legs, having broken both her knee-pans
eight months ago, and she has never been
able to use her limbs since/’— Passive motion
was directed, and she was ordered to try to
extend her legs when they were bent. At first
she could effect but little however, by re-
peated trials, she gradually recovered the use of
her limbs. Mr. John Hunter, who raised sur-
gery into a science, and who seems to have been
the first who attended to the principles on which
the practice of surgery ought to be regulated,
always dwelt most ably upon this subject in his
lectures. Patients, from the pain which passive
motion produces, and the slow return of action
in the muscles, are indisposed to suffer the one
or to make trials of the other ; but without them
there can be no recovery.

The degree of approximation of the bone is,
as I have stated, a matter of great consequence.
The bone is rarely, if ever, brought into con-
tact so as to be united in the transverse frac-
ture by ossific union ; but the less the dis-
tance between the bones, the greater is the
power which the muscle reacquires : for, in
proportion as the muscle is shortened is it
weakened | therefore the surgeon should bring
the bones as near together as he can to render
the ligamentous union as short as is possible,
and consequently to leave the muscle with as
much of its original power as the nature of the
accident permits.

Case.

Degree of
approxima-
tion.

ON FRACTURES

Ligamen-
tous union

Union by
ligament,
in experi -
ments.

Of the 'perpendicular Fracture of the Patella .

We have in the collection at St. Thomas’s
Hospital a patella, one-fourth of which has been
broken off; the edge is smooth, and no ossific
union of the piece from which it had been se-

parated appeared to have been produced.

A gentleman consulted me who had about
one-third of the patella separated from the other
part of the bone ; it had united by ligament, for
there was free motion between the fractured
piece of bone and that from which it had been
removed. He recovered quickly from this in-
jury, and it influenced his power of walking very
little.

These circumstances surprised me, because I
saw no reason why the bone should not be
united when broken perpendicularly, as I
thought the muscles would have a tendency to
bring the parts together. I made it therefore a
subject of experiment.

EXPERIMENT I.

July 31st, 1818, I broke the patella of a dog,
by placing a knife upon it in the longitudinal di-
rection, having first drawn the integuments aside.

and on the 12th of September following I ex-
amined the part, when I found the two portions
of bone considerably separated from each other,
and united by ligament. The cause was as fol-
lows: when I had divided the bone, the knee
became bent, the condyles of the os femoris

OF THE KNEE.

pressed against the inner side of the patella,
and thrust the parts asunder, and only a
ligamentous union had taken place. (See
Plate.)

EXPERIMENT II.

August 2d, 1818, I broke in the same man-
ner the patella of a rabbit, and examined the
parts on September 3rd, when I found the two
portions of bone widely separated, and united
only by ligamentous matter, I now began to
think it impossible for the patella to unite by
bone, but determined to make another experi-
ment to determine this point

EXPERIMENT III.

I divided the patella longitudinally in a dog,
but took care that the division should not ex-
tend into the tendon above or to the ligament
below it, so that there should be no separation
of the two portions, I examined it three weeks
after, and found it united ; no separation exist-
ing between the two portions*. (See Plate.)

It appears, then, that under longitudinal and
transverse fracture, a ligamentous union is gene-
rally produced, and that it arises from the sepa-
ration produced in the bone ; and that if it
cannot separate, but its parts remain in contact,
then ossific union will be produced.

In the summer of 1819, Mr. M. was thrown
from his gig as he was passing along the Strand,

* Th£ bone was, under maceration, found united in part by
bone, and in part by cartilage, not yet completely ossified.

Union by
bona.

ON FRACTURES

Treatment.

From

Violence or
ulceration.

Case.

and fractured Ins patella by the fall transversely ,
and the lower portion of the bone was also bro-
ken perpendicularly, so that it was divided into
three pieces. The transverse fracture united
as usual by ligament; but the perpendicular, by
bone. Mr. Parrott, of Tooting, who also attend-
ed the case, writes in these words:—' u Dear Sir,
I have great pleasure in replying to your letter;
the longitudinal fracture of the patella of Mr,
M. has become very firmly consolidated, but
there is a line or ridge to be traced upon the
surface of the bone, which marks distinctly the
place where it had been separated.

JOHN PARROTT, JUN.?'

Tooting.

In the longitudinal or perpendicular fracture
of the patella, the best treatment is, to extend
the leg, to use local depletion, and evaporating
lotions ; in a few days to apply a roller around
the limb, and then a laced knee-cap with a strap
which buckles around the knee above and below
the patella.

Of compound Fracture of the Pa tella .

These occur from injury, or from an ulcera-
tive process under peculiar circumstances.

The cases which I have seen of this accident,
are as follows :

CASE I.

A man was admitted into Guy’s Hospital,
under Mr* W. Cooper, with a compound fracture
of this bone; violent inflammation followed; sup-

OF THE KNEE,

puration ensued, with the highest degree of con-
stitutional irritation ; and no opportunity was
given for amputation from the great swelling of
the thigh ; and this man died. The bone is in
the museum of St, Thomas’s Hospital, as dis-
united as at the first moment of the accident.

CASE IL

A man was admitted into St* Thomas’s Hos- Case»
pital, under the care of Mr. Birch, with a frac-
ture of the patella and a small wound extend-
ing into the joint. The knee was fomented
and poulticed ; inflammation and suppuration
followed ; and this man in a few days died with
the highest symptoms of constitutional irrita-
tion.

CASE III.

Mr. Hawker, surgeon, called me to visit a Case,
man who was just arrived in London ; who was
at work at a warehouse up one pair of stairs,
and hearing the signal for dinner, and seeing
the doors of the warehouse open, he walked
quickly out and fell into the street. By this
fall he had a compound fracture of the patella.

The limb was attempted to be saved. The
joint suppurated, the discharge became exces-
sively great, and the symptoms of irritation ran
so high that I thought he would not recover;
but he became somewhat better, and i advised
him to go into the country. I afterward heard
that he gradually recovered with an anchylosed
joint.

ON FRACTURES

CASE IV.

Mr. Redhead, residing at Kennington Cross,
aged 89 years, was thrown from his gig on the
18th of June, 1819, against a cart-wheel. His
knee came violently in contact with the wheel,
which fractured his patella and opened the joint.
Mr. Dixon, of Newington Butts, wafc sent for,
and he found that the knee had bled freely from
a wound on its outer side, from which the synovia
freely escaped, and which readily admitted his
finger to the shattered patella. The accident
happened at ten o’clock, and I was sent for by
Mr. Dixon, and when X met him at four o’clock
I found a wound through which I readily passed
my finger into the joint, and the patella was
not broken transversely, but, as I have ex*
pressed it, shattered, that is, broken into several
pieces, and a small piece which was separated
from the rest 1 removed. It was agreed be-
tween Mr. Dixon and myself that the limb
should be attempted to be saved, for the patient
was of a spare habit, and from bis great com-
posure shewed he was not of an irritable consti-
tution. 1 passed a suture through the integu-
ments, knowing the difficulty of keeping the
wound closed on account of the continued
escape of synovia, but taking the utmost care
that the ligament should not be included in the
suture. Adhesive plaister was also applied over
the wound, and rollers, lightly put on, which
were kept constantly wet with spirits of wine
and water. The leg was placed in the ex-
tended position, and he was ordered not to

OF THE KNEE,

move it in the slightest degree, and to live on
fruit.

Saturday . He had passed a very good night,
and was free from pain or fever.

Sunday night . He was restless, and it was
thought delirious.

Monday morning . He had a dose ofGl. Ricini,
which relieved him from his feverish feelings.

Tuesday . He stated he had a good night, and
he afterwards had no bad symptom. As there
was no swelling, no inflammation, and scarcely
any pain, the suture was not removed until the
30th of June, when the adhesive plaister was
renewed. He recovered without any untoward
accident. Mr. Dixon ordered him from bed in
a month. At the end of five weeks Mr. D, gave
the joint slight passive motion, and on the 7th
of August he walked across his room.

If the laceration be extensive, or the contu-
sion very considerable in these cases, the ope-
ration of amputation will be required \ but if
the wound be small, and the patient unirri table,
and no sloughing of the integuments or liga-
ment is likely to occur from the nature of the
accident, it will be best to try to save the limb ;
and the treatment of Mr. Redhead’s case is that
which I should pursue. The principal object is
to produce adhesion immediately, and every
means in our power must be used to effect it.
I know well that sutures are generally objec-
tionable, and I never employ them, if I can pos-
sibly succeed without them, but in moveable
parts, in those which are unsupported, and in
those through which a secretion is liable to

ON FRACTURES

force its way, they are not only justifiable but

highly necessary.

A compound fracture of the patella will be
sometimes produced by an ulcer in the follow-
ing manner.

CASE.

ulceration. A wo man was admitted into Guy’s Hospital
in 1816, with a simple fracture of the patella*
which had long been united by a ligament of
about three inches in extent. Ulcers were formed
upon different parts of the body, and unfortu-
nately one of these upon the integuments over
the union of the patella. It became sloughy*
and extended through the new ligament to the
joint which it laid open ; violent constitutional
irritation succeeded ; a copious suppuration was
produced, and no opportunity was given of am-
putating the limb, for the inflamed and swollen
state of the thigh forbad it. This woman died.

On Oblique Fractures of the Condyles of the Os

Femoris into the Joint .

Rare, These cases are of rare occurrence, but when

they happen it is difficult to prevent deformity,
and to restore the patient to a sound and useful
limb. They are known by the great swelling
of the joint with which they are accompanied,
by the crepitus which is felt in moving the
joint, and by the deformity with which they
if either are attended. The fracture is sometimes of the
inner and sometimes of the outer condyle, and
the bone is split down into the joint.

OF THE KNEE*

Whether the external or internal condyle is Treatment,
broken, the same treatment is required* The
limb is to be placed upon a pillow in the straight
position, and evaporating lotions and leeches
are to be used to subdue the swelling and in-
flammation. When this object has been effected,
a roller is to be applied around the knee, and
a piece of stiff pasteboard, about sixteen inches
long, and sufficiently wide to extend entirely
under the joint, and to pass on each side of
it, so as to reach to the edge of the patella, is
to be dipped in warm water, and applied under
the knee and confined by a roller. When this
is dry it has exactly adapted itself to the form
of the joint, and this form it afterwards retains,
so as best to confine the bones. Splints of wood
or tin may be used on each side of the joint, but
they are apt to make uneasy pressure. In five
weeks passive motion of the limb may be gently
begun, to prevent anchylosis. I prefer the
straight position in these cases, because the
tibia presses the extremity of the broken con-
dyle into a line with that which is not injured.

Examples of compound fractures of the com Compound
dyles are very unfrequent ; the following was fracturc‘
under the care of Mr. Travers in St. Thomas’s
Hospital, who was so kind as to send me the
following history of it.

Michael Dixon was admitted into St. Tho-
mas’s Hospital, September 17th, 1816, for a
fracture of the lower extremity of the femur,
occasioned by his legs being entangled in the
spokes of a carriage-wheel in motion. There
was much displacement of the fractured bone,
and a small wound opposite the external con-

ON FRACTURES

dyle. Upon examination, it was evident that
the fracture had extended nearly in the di-
rection of the axis of the bone, in addition
to a transverse fracture of the shaft of the
bone above the joint ; the external condyle
was moveable and thrown out of its place du-

ring the accident, as if it had been drawn by
the leg which was twisted inwards. The limb
was laid in a fracture-box, in a semiflexed posi-
tion on the heel 5 the constitutional disturbance
was very slight.

Oct. 5. The external condyle is still moveable \
the integuments over it are ulcerated: so as to
denude the bone ; the health remains good.

Nov. 5. The broken bone protrudes and ap-
pears to be dead ; it is surrounded by fungous
granulations, and there is but little discharge.

Nov . 18. The protruded bone was gently
twisted off by forceps shewing it to be the ex-
ternal condyle with its articular surface ; there
still protruded a small portion of bone, but this
soon healed over ; the limb was now placed in
an extended position, as anchylosis was consi-
dered unavoidable.

Dec . 1. The boy has recovered almost the
perfect use of his limb, and is enabled to bend
and extend it without pain.

Dec . 6. The boy was discharged from the
hospital. The wound was healed, and he can
walk tolerably well with a stick.

On the February following he called at the
hospital, walking without any support, and
having free use of the joint.

Fractures of the Body of the Femur just

OF THE KNEE* 93

above the condyles require the bent posh Fractures

* A * just above

tion of the knee, to prevent deformity, which the con-
is sore to follow if the limb be placed m <tyles*
the straight position, and most miserable
union I have thus seen produced. The thigh
ought to be put over the double inclined
plane, to constantly extend the condyles in a
line with the shaft of the hone, and a roller
is to be applied around the lower parts of the
thigh-bone, to assist in pressing the bones to-
gether. These cases I have seen occur in per-
sons prior to the age of twenty years, and it has
appeared to me that the epiphysis has been
broken off, but I have also known it happen in
very old persons, and in one instance prove de-
structive to life.

The Head of the Tibia is sometimes obliquely oblique
broken, and if it be fractured into the joint the th1oibi?in-
treatment which it requires is similar to that tothejoint‘
which is necessary in the oblique fracture of
the condyle of the os fern oris, that is, first,
the straight position of the limb, because the
femur preserves the proper position of the frac-
tured tibia, by Being a splint to its upper
portion, keeping the articular surfaces equal ;
secondly, a roller, to press one part1 of the
broken surface against the other ; thirdly, a
splint of pasteboard, to assist in the preserva-
tion of that pressure \ and fourthly, early pas-
sive motion to prevent anchylosis.

But if the fracture of the tibia be oblique, Fracture

. . * lust below

but not into the joint, then it is best to place the joint,
the limb upon the double inclined plane ; and
as the cause of deformity is the elevation of the
lower portion of the tibia, which is drawn up

Union with
the tibia.

Produced
by violence
or relaxa-
tion.

ON FRACTURES OF THE KNEE*

on either side of the knee-joint, as the frac-
ture is in the inner or outer side of the tibia,
the weight of the leg keeps the limb constantly
extended, as it hangs over the angle of the in-
clined plane, and thus brings the bone into as
accurate apposition as the case permits.

On Dislocations of the Head of the Fibula.

The fibula joins the tibia, three-quarters of an
inch below the articulation of the knee. Its
head is inclosed in a capsular ligament which
unites it to the tibia, to which it is also joined
through the greater part of its length by the in-
terosseous ligament.

This bone is liable to dislocation both from
violence and from relaxation. I have only seen
one case of it from violence, and in that in-
stance it was connected with the compound
fracture of the tibia.

■ Briggs, of whose dislocation of the tibia

I have given an account, had at the upper part
of the other leg a compound fracture of the
tibia and dislocation of the head of the fibula.
The limb was attempted to be saved, but the
constitutional irritation ran so high that ampu-
tation was obliged to be performed, which was
done by my colleague Mr. Lucas, and the man
did well.

Dislocations of the head of the fibula from
relaxation are more frequent, and the head of
the bone is in these cases thrown backwards,
and is easily brought into its natural connection
with the tibia, but it directly again slips from
Its position* This state produces a consider-

ON DISLOCATIONS OF THE ANCLE®

able degree of weakness and fatigue in walk-
ing, and the person suffers much from exercise.
As in these cases there is a superabundant
secretion of synovia and distension of ligament,
repeated blistering is required to promote ab-
sorption, and afterwards a strap is to be buckled
around the upper part of the leg, to bind the
bone firmly in its natural situation, which gives
support and at least prevents the increase of
the malady.

ON DISLOCATIONS OF THE ANCLE-

JOINT.

The bones which enter into the composition of
the ancle-joint are the tibia, fibula, and astraga-
lus. The tibia forms an articulating surface at
its lower part, which rests upon the astragalus,
and there is a projection on the inner side of
the lower portion of the bone which forms the
malleolus internus, and this part is articulated
with the side of the astragalus. The fibula
projects beyond the tibia at the outer ancle,
and forms there the malleolus externus, which
has also an articulating surface for the astra-
galus. The astragalus, which is the superior
tarsal bone, rises between the malleoli, and the
lower part of the tibia moves upon it prin-
cipally in flexion and extension.

Thus then nature has strongly protected this
part by the deep socket formed by the two
bones of the leg and by the ball of the astraga-
lus, which is received into it.

Structure
of thejoint.

Bones.

ON DISLOCATIONS OF

Capsular

ligament.

Peculiar

ligaments.

Dislocation

snwards.

A capsular ligament, lined by a synovial
membrane, joins the tibia and fibula to the as-
tragalus. A strong ligament unites the tibia
to the fibula, but without any intervening arti-
cular cavity, as the ligament proceeds from
one surface of bone and is received into the
other.

The peculiar ligaments joining the tibia and
fibula to the tarsus consist of a deltoid liga-
ment, which proceeds from the tibia to the
astragalus, os calcis and os naviculare. The
fibula is united at its lower end by three ex-
cessively strong ligaments, one anteriorly from
the malleolus externus to the astragalus, one
inferiorly to the os calcis, and the third to
the astragalus posteriorly ; and it is the strong
union of this bone which leads to its being
more frequently fractured than dislocated ;
and even when the tibia is luxated the fibula
is fractured in two of the species of dislocation
of the ancle, and generally in all ; but when
the tibia is thrown outwards I have known the
fibula escape a fracture.

I have seen the tibia dislocated at the ancle
in three different directions, forwards, inwards,
and outwards ; but a fourth species of dislo-
cation is said to occur occasionally, viz. back-
wards.

Of the simple Dislocation of the Tibia inwards .

This is the most frequent of the dislocations
of the ancle ; the tibia, in this accident, has its
internal malleolus thrown inwards, which is so
forcibly projecting against the integuments as to

THE ANCLE.

threaten their bursting. The foot is thrown
outwards, and its inner edge rests upon the
ground ; about three inches above the outer ancle
there is a deep depression, and a general tume-
faction, from extravasation, surrounds the joint.

Upon dissection, the internal appearances are
as follow : the end of the tibia rests upon the
inner side of the astragalus, instead of on its upper
articulatory surface, and if the accident has oc-
curred from a person jumping from a consider-
able height, the lower end of the tibia, where
it is connected to the fibula by ligament, is
split off, and remains connected with the fibula,
which is also broken from two to three inches
above the joint, and the broken end of the fibula
is carried down upon the astragalus occupying
the natural situation of the tibia ; the malleolus
externus of the fibula remains in its natural situa-
tion, with two inches of the fibula and the split
portion of the tibia ; the capsular ligament at-
tached to the fibula at the malleolus externus
and the three strong fibular tarsal ligaments, re-
main uninjured.

This accident generally happens by jumping
from a considerable height, or in running vio-
lently with the toe turned outwards, when the
foot is suddenly checked in its motion while the
body is carried forwards upon the foot, and the
ligaments on the inner side of the ancle give
way.

For the reduction of this dislocation the pa-
tient is to be placed upon a mattress properly pre-
pared, and is to rest on the side on which the
injury has been sustained ; he is then to bend
the leg at right angles with the thigh, so as
to relax the gastrocnemii muscles as much

Symptoms,

Dissection,

Mode of
reduction.

ON DISLOCATIONS OF

Treatment.

as is possible, and an assistant grasps the foot,
and gradually draws it into a line with the
leg. The surgeon fixes the thigh and presses
the tibia downwards, and thus forces it upon
the articulating surface of the astragalus. Great
force is required if the limb be placed in the
extended position, from the resistance the gas-
trocnemii give ; and it is pleasing to observe,
after most violent attempts, a well-informed sur-
geon gently bend the limb, and, under a com-
paratively slight extension, return the parts to
their natural situation.

When the limb lias been reduced, it is still to
remain upon its outer side in the bent position,
with the foot well supported ; a many-tailed ban-
dage is placed over the part to prevent it slipping
from its place, and this is to be kept wet with an
evaporating lotion. Two splints are then to be
applied ; and that upon which the outer part of
the limb rests is to have a foot-piece, to give
support to the foot, prevent its eversion, and
preserve it at right angles with the leg. If
much inflammation succeeds, leeches are to be
applied to the parts, and the constitution will
require relief by taking blood from the arm, and
by attention to the bowels ; but I shall say no
more on this subject until I describe compound
dislocation. A person who has had this accident
maybe removed from his bed in five or six weeks,
long straps of plaister being passed around the
joint to keep the parts together, and he may
be suffered to walk on crutches ; but from ten
to twelve weeks elapse before be has the free
motion of his foot ; and much friction and pas-
sive motion are required after eight weeks to
restore the motion of the joint.

THE ANCLE*

Vf the simple Dislocation of the Tibia forwards.

In this accident the foot appears much short- symptoms,
ened, the heel proportionally lengthened, and
the toes are pointed downwards. Upon dissection Dissection,
the tibia is found to rest upon the upper surface
of the os naviculare and os cuneiforme in-
ternum, quitting all the articulatory surface of
the astragalus, excepting a small portion on its
fore part, against which the tibia is applied*

The fibula is broken, and its fractured end ad-
vances with the tibia, and is placed by its side ;
its malleolus externus remains in its natural situa-
tion, but the fibula is broken about three inches
above the joint ; the capsular ligament is tom
through on its fore part ; the deltoid ligament is
only partially lacerated, and the three ligaments
of the fibula remain unbroken. This accident Cause*
arises from the body falling backwards whilst
the foot is confined, or from a person jumping
from a carriage in rapid motion, with the toe
pointed forwards.

The treatment consists in attending to the foU Reduction,
lowing rules : the patient is placed in bed on his
back ; one assistant grasps the thigh at its lower
part, and draws it towards the body, and another
pulls the foot in a line a little before the axis of
the leg, and the surgeon pushes down the tibia
to bring it into its place. The same prin- Treatment,
ciples are held in view in this mode of reduction
as in the former, with respect to the relaxation
of the muscles. A many-tailed bandage must
be lightly applied dipped in an evaporating

100

ON DISLOCATIONS Of1

Symptoms.

C ase.

lotion ; and the local and constitutional treat-
ment is the same as in the dislocation inwards.

As to position, it is best to keep the patient
upon the heel resting on a pillow, and to have a
splint properly guarded on each side the leg,
having foot-pieces to keep the foot well sup-
ported at right angles with the leg, so as to pre-
vent the muscles again drawing it from its place*
As in live weeks the fibula will be united, there
will then be no danger in taking the patient
from his bed j and gentle passive motion may
be begun*

Of the partial Dislocation of the Tibia forwards*

This bone is sometimes partially luxated for-
wards, so as to rest half on the os naviculare,
and half on the astragalus. The fibula, in
this accident, is broken ; the foot appears but
little shortened, nor is there any considerable
projection of the heel. The signs of this acci-
dent are as follow : The foot is pointed down-
wards, and a difficulty is experienced in the
attempt to put it flat on the ground : the heel is
drawn up, and the foot is in a great degree im-
moveable.

The first case of this kind which I saw, was in
a very stout lady who resided at Stoke Newing-
ton, and had by a fall, as she said, sprained her
ancle. When I examined the limb, I found the
foot immoveably fixed and pointed downwards,
attended with great pain just above the ancle.
I attempted to draw the foot forwards and
bend it, but could not succeed. Some years
after I saw this lady at Bishop Stortford, walking

THE ANCLE*

101

upon crutches ; her toe was pointed, and she
was unable to bring any other part of the foot
to the ground ; the degree of distortion was less
than that which occurs in the complete luxation
of the bone forwards ; but now all tension hav-
ing been subdued, the nature of the injury was
more evident, though I should not have known
it decidedly, but from an examination of a
foot shewn me by my friend and late appren-
tice, Mr. Tyrrell, who was so kind as to give
me the parts, and of which I have given a
plate. The articular surface of the lower part
of the tibia was divided into two ; the ante-
rior part was seated upon the os naviculare ;
the posterior upon the astragalus; these two
articulatory surfaces were formed at the lower
extremity of the bone, both of which had
been rendered smooth by friction. The fibula
was found fractured. (See Plate.) The result
of this dissection clearly proves the necessity
which exists in these accidents, however slight
they may at first sight appear, of not resting
satisfied until the foot be returned into its natu-
ral position ; for if neglected in the commence-
ment, severe inflammation and tension will pre-
vent even a forcible extension being afterwards
useful ; and if still longer neglected, the changes
in the state of the muscles, and the union of the
fibula will preclude the possibility of a reduction,
even under the most violent attempts. The
mode of reduction and after-treatment will in no
respect differ from that required in the perfect
dislocation of the bone, either as respects the re-
laxation of the muscles, the bandages, or the
local and constitutional treatment.

Dissection,

Treatment.

102

ON DISLOCATIONS OF

Symptoms.

Dissection.

Of the simple Dislocation of the Tibia outwards*

This luxation is the most dangerous of the
three, for it is produced by greater violence,
is attended with more contusion of the integu-
ments, more laceration of ligament, and greater
injury to the bone ; the foot is thrown inwards,
and its outer edge rests upon the ground.
The malleolus externus projects the integuments
of the ancle very much outwards, and forms so
decided a prominence that the nature of the
injury cannot be mistaken ; the foot and the
toes are pointed downwards.

In the dissection of this accident, it is found
that the malleolus internus of the tibia is ob-
liquely fractured and separated from the shaft
of the bone ; the fractured portion sometimes
consists only of the malleolus, at others, the
fracture passes obliquely through the articular
surface of the tibia, which is thrown forwards
and outwards upon the astragalus, before the
malleolus externus. The astragalus is some-
times fractured, and the lower extremity of the
fibula is broken into several splinters. The
deltoid ligament remains unbroken, but the
capsular ligament is on its outer part torn ;
the three fibular tarsal ligaments remain whole
in most cases, but when the fibula is not
broken, they are ruptured ; none of the ten-
dons are lacerated, and haemorrhages scarcely
ever occur to any extent, as the large arteries
generally escape injury. This accident happens
either by the wheel of a carriage passing over the

THE ANCLE.

103

leg, or by the foot being twisted inwards in
jumping or falling.

The mode of reduction consists, in placing Reduction,
the patient upon his back, in bending the thigh
at right angles with the body, and the leg at
right angles with the thigh ; the thigh is then
grasped under the ham by one assistant, and
the foot by another ; and thus an extension is
made in the axis of the leg, whilst the surgeon
presses the bone inwards towards the astragalus.

The limb, in the simple dislocation, is to be
laid upon its outer side, resting upon a splint,
with a foot-piece, and a pad is to be placed
upon the fibula, just above the outer angle, and
extending a few inches upwards, so as in some
measure to raise that portion of the leg, and
support it so as to prevent the tibia and fibula
slipping from the astragalus, as well as to lessen
the pressure of the malleolus externus upon the
integuments, where they have sustained injury.

The local and general treatment will be the Treatment,
same as in the former cases, although more de-
pletion is required as greater inflammation suc-
ceeds ; the greatest care is required that the
foot does not become twisted inwards or pointed
downwards, as either of these states prevents the
limb from being afterwards useful. Passive mo-
tion should be given to the joint in six weeks
from the accident, when the patient may rise
from his bed, and be allowed to walk upon
crutches, unless great swelling of the ancle
prevents it. In general in these cases from
ten to twelve weeks elapse before the cure is
complete.

104

ON COMPOUND DISLOCATIONS OF

On the compound Dislocation of the Ancle-joint.

Opening
into the
joint.

t/jcal

effects.

These accidents take place in the same direc-
tion as the simple dislocations, and the bones and
ligaments suffer in the same manner as in those
dislocations. The only difference therefore in
these cases is, that the joint is laid open by
a wound in the integuments and ligaments,
opposite to the laceration of the skin, by which
the synovia escapes, and through which the
ends of the bone protrude ; this opening in the
integuments is generally occasioned by the bone,
but sometimes by the pressure of some uneven
surface on which the limb was thrown.

The bones being replaced by the same means
as are employed in the simple dislocation, the
effect of this accident upon the parts composing
the joint is as follows. The synovia, as I have
stated, escapes by a large wound in the mem-
brane secreting it, and in a very few hours in-
flammation begins ; and when an additional
quantity of blood is first determined to the part
an abundant secretion issues from this membrane,
and is discharged through the wound \ the liga-
ments participate in the inflammation as well as
the extremities of the bones, which enter into
the composition of the joint. The inflammation
of the internal secreting membrane of the joint
in about five days proceeds to suppuration ;
at first but little matter is discharged, but it
continues until it becomes very abundant, and
the lacerated parts of the ligaments and perios-
teum also secrete matter. Under this process
of suppuration the cartilages become partially

THE ANCLE.

105

or wholly absorbed, but generally partially only ;
but the ulceration of the cartilage is a very slow
process and attended with severe constitutional
irritation, and often lays the foundation of ex-
foliation of the extremities of the bones. When
they are completely absorbed, granulations arise
from the surface of the bones and from the
inner side of the synovial membrane, and these
inosculate and fill up the cavity between the
extremities of the bones. Sometimes we find
after accidents to joints, that the adhesive pro-
cess occurs at one part and that the cartilage is
not absorbed, whilst granulations are formed at
others where the cartilage was removed by ul-
ceration, and I have seen after inflammation in
joints the cartilages remain and their surfaces
adhere.

This inosculation of granulations nor the pro-
cess of adhesion, do not lead to permanent an-
chylosis, for if passive motion be begun as soon
as the parts from cessation of pain and inflamma-
tion will permit, motion will be restored, not
always entirely, but with very little diminution ;
and the other parts of the tarsus will acquire such
an extent of motion as to render the deficiency
in the mobility of the ancle joint but little appa-
rent; the aperture in the ligament is filled by
granulations; and with respect to the extremities
of the bone, when they are joined by ossilic
union, it is by the deposit of cartilage and by a
secretion of phosphate of lime, in the usual man-
ner in which bones are formed and repaired.

Thus then the compound dislocation of the
ancle is leading to inflammation over a very
extensive secreting surface, as well of bone

lOQ ON COMPOUND DISLOCATIONS OF ’

as of ligament ; it next produces an extended
suppuration over the lining of the joint, which
leads to much constitutional derangement, and
further it becomes the source of an ulcerative
process, more or less extensive according to the
treatment pursued, by which the cartilage is
partly or wholly removed, and by which the ir-
ritative fever is supported for a great length of
time ; and the ulceration sometimes extends
over the extremities of the dislocated bones,
leading to great additional constitutional irrita-
tion and continued disease from exfoliation,

constitu- These local effects are accompanied by the

. tionaf . . 1 , . . J .

effects. common symptoms of constitutional irritation.
In two or three days from the accident, or
sometimes as early as twenty-four hours, the
patient complains of pain in his back and in
bis head, shewing the influence of the acci-
dent on the brain and spinal marrow. The
tongue is furred, white if the irritation be slight,
yellow if greater, and brown almost to black-
ness if it be considerable ; the stomach is disor-
dered, there is loss of appetite, nausea, and some-
times vomiting; the intestines cease to secrete,
and the glands connected with them, as the liver,
&c. ; costiveness is therefore an attendant sign.
The skin has its secretion stopped, it is hot and
dry ; the kidneys also have their secretion di-
minished ; the urine is high-coloured and small
in quantity. The heartbeats more quickly and
the pulse becomes hard, which is the pulse of
constitutional irritation from local inflamma-
tion, and in great degrees of it becomes irregular
and intermittent ; the respiration is quicker in
sympathy with the quicker circulation ; the

THE ANCLE,

1 07

nervous system becomes additionally affected in
high degrees of local irritation ; restlessness,
watchfulness, delirium, subsultus, and sometimes
tetanus occur* These are the usual effects of
local irritation upon the constitution, occurring
in different degrees according to the violence of
the injury, the irritability of the constitution,
and the powers of restoration.

The cause of the violence of these symptoms
is the wound which is made into the joint, and
the great efforts required for its repair, for when
there is no wound, and the process of adhesion
can unite the part, little local inflammation or
constitutional irritation occur ; and if this be the
cause of the violence of the symptoms, the
principle in the treatment of this accident is
easily comprehended, and it consists in closing
the wound as completely as is possible, to assist
nature in the adhesive process by which the
wound is to be closed, and to tender suppu-
ration and granulation less necessary for the
union of the opened joint.

The first question which arises upon this sub-
ject is the following : Is amputation generally
necessary in compound dislocations of the ancle ?
My answer is, certainly not ; thirty years ago
it was the usual practice to amputate limbs for
this accident, and it was then thought abso-
lutely necessary for the preservation of life by
some of our best surgeons 5 but so many limbs
have been of late years saved, indeed I may say
so great a majority of cases, that such advice
would now be considered not only injudicious
but cruel. It is far from being my intention to
state that amputation is never required, but
1

Cause of
the symp-
toms.

Principle
of cure.

Is amputa-
tion re-
quired?

108

ON COMPOUND DISLOCATIONS OF

Treatment*

A rterv
divided.

Loose
pieces of
bone.

only to observe that in by far the greater number
of these accidents, that this operation is unne-
cessary.

But before I give the proofs of what I have
advanced, let me state the mode of treatment
which is to be pursued in these cases.

When the surgeon examines the limb, he
finds a wound of greater or less size, according
to the degree of the injury. The extremity
of the tibia projects if the dislocation of the
tibia be inwards ; and the tibia and fibula
are protruded, if the dislocation of the former
be at the outer ancle. The ends of the bones
are often covered with dirt, from their hav-
ing reached the ground. The foot is loosely
hanging on the inner or outer side of the leg,
according to the direction of the dislocation.
Sometimes, though very rarely, a large artery
will be divided ; and it is surprising that the pos-
terior tibial artery so generally escapes; the ante-
rior tibial being the only vessel I have known
tom. The arrest of haemorrhage is the first
object ; and for this purpose, if the anterior
tibial artery be wounded, it must be secured by
ligature. The extremity of the bone is to be
washed with warm water, as the least extrane-
ous matter admitted into the joint will pro-
duce and support a suppurative process, and
the utmost care should be taken to remove
every portion of it adhering to the end of the
bone.

If the bone be shattered, the finger is to be
passed into the joint, and the detached pieces
are to be removed ; but this is to be done hi
the most gentle manner possible, so as to da

THE ANCLE.

309

too unnecessary injury ; and if the wound be so
small as to admit the finger with difficulty, and
small loose pieces of bone can be felt, the integu-
ments should be divided with a scalpel upwards,
to allow of such portions being removed without
violence ; the incision should be so made as to
leave the joint with as much covering of integu-
ment as possible. The integuments are some-
times nipped into the joint by the projecting
bone, and it cannot be reduced, when this is the
case, without making an incision upwards, to
allow of the skin being brought from under
the bone ; and when the edges of the incised
wound are afterwards brought together, no ad-
ditional evil arises from the extension of the
wound.

The mode of reducing the bone is (in oilier
respects) similar to what we have already de-
scribed, when speaking of simple dislocation,
by bending the leg upon the thigh, so as to
relax the muscles before the extension is made.
When the bone has been reduced, a piece of lint
is dipped in the blood and applied wet over the
wound upon which the blood coagulates, and forms
the most natural, and as far as I have seen, the
best covering to the wound. A many-tailed band-
age is then applied, the portions of which should
not be sewn together, but passed under the leg,
so that any one piece may be removed when
it becomes stiff, and by fixing another to its
end, it can always be applied afresh, without
any disturbance to the limb ; this bandage is
to be kept constantly wet with spirits of
wine and water. A hollow splint, with a
foot-piece at right angles, is to be applied on

Integu-

ments.

Reduction.

Constitu-
tional treat-
ment.

ON COMPOUND DISLOCATIONS OF

the outer side of the leg, in the dislocation in-
wards, and the leg is to rest upon its outer side:
but in the dislocation outwards it is best to keep
the limb upon the heel, with a splint both upon
the outer and on the inner side, with an aperture
in the splint opposite to the wound.

The patient’s knee is tobe slightly bent in each
dislocation, to relax the gastrocnemius muscle.
The foot must be carefully prevented being
pointed ; great care being taken to keep it at
right angles with the leg, otherwise the limb will
be useless when the wound is healed. The pa-
tient is to be placed on a mattress, and a
pillow is to reach from half way above the knee
to beyond the foot, and another is to be rolled
under the hip, to support the upper part of the
thigh-bone.

Blood-letting must be bad recourse to or not
according to the powers of the constitution, as
it is necessary to bear in mind that the patient
has a great trial of his powers to undergo,
and will require, in the end, all the support
which his strength can receive. Purgatives
must also be used with the utmost caution, for
there cannot be a worse practice, when a limb
has been placed in a good position, and adhesion
is proceeding, than to disturb the processes of
nature by the frequent changes of position which
purges produce ; and I am quite sure, that in
cases of compound fracture, I have seen pa-
tients destroyed by their frequent administra-
tion. That which is to be done by bleeding, and
emptying the bowels, should be effected at the
first hour of the accident, before the adhesive
inflammation arises ; after which the liquor am-

Ill

THE ANCLE.

mon i ac acetatis and tinctura opii, form the pa-
tient’s best medicine, with a slight aperient at in-
tervals.

If the patient complains of considerable pain spec^^J
in the part in four or five days, the bandage may
be raised, to examine the wound ; and if there be
much inflammation, a corner of the lint should be
lifted from the wound to give vent to any matter
which may have formed ; but this ought to be
done with great circumspection, as it is in dan-
ger of disturbing the adhesive process if that be
proceeding without suppuration. By this local
treatment it will every now and then happen that
the wound will be closed by adhesion, but if in
a few days it be not, and suppuration take place,
the matter should havean opportunity of escaping ;
and the lint being removed, simple dressings
should be applied. After a week or ten days if
there be suppuration with much surrounding in-
flammation, poultices should be applied upon the
wound, leeches in its neighbourhood and upon
the limb at a distance the evaporating lotion
should still be employed ; but as soon as the in-
flammation is lessened, the poultices should be
discontinued, as they encourage too much secre-
tion, and relax the blood-vessels of the part, %

so as to prevent the restorative process.

If the cure proceeds favourably, in a few weeks
the wound is healed with little suppuration. If Result,
less favourably, acopious suppuration takes place,
the wound is longer in healing, and exfoliation of
the extremity of the bone still further retards
the cure. The motion of the joint is not always
lost, but is sometimes in a great degree restored ;
but this depends upon the greater or less

112

ON COMPOUND DISLOCATIONS OF

Cases,

extent of suppuration or ulceration. The pa-
tient after three months walks with crutches un-
der the most favourable circumstances, but is
many months in others, and he bears upon the
foot at different periods of time in different de-
grees of injury, as in compound fracture when
adhesion is not at first produced, only that the
patient is in these cases longer in recovering.

I shall now proceed to state the cases which
have induced me to say amputation, as a gene-
ral rule, is improper in these cases.

The first circumstance which led me to doubt
the true judgment of the opinion which recom-
mended an indiscriminate amputation of these
injuries, was this—

CASE I.

I was, many years ago, going into the country
with a friend of mine, and we met with a sur-
geon in our journey, who put this question—
“ What do you do in compound dislocations of
the ancle joint V9 I do not recollect the reply,
but he proceeded to say, I have had a case of
compound dislocation of the ancle joint under
my care, in which I told the patient he must
lose his limb ; not approving this advice, his
friends sent for another surgeon, who said he
thought he could save it ; the patient placed
himself under his care, and the man, he added,
was recovering.

CASE IL

More than twenty years ago I received from
Mr. Lynn, of Woodbri dge, now Dr. Lynn, the

THE ANCLE*

Astragalus of a man, broken into two pieces,
which *he had taken from a dislocated ancle-
joint. His letter is as follows :

DEAR SIR,

J. York, aged 52 years, being pursued by
some bailiffs, jumped from the height of seve-
ral feet to avoid them. The tibia and a part of
the astragalus protruded at the inner ancle. X
immediately returned the parts into their na-
tural situation. Suppuration ensued, and in
five weeks a portion of the astragalus sepa-
rated, and another piece a week afterwards,
which when joined formed the ball of that
bone. In three months the joint was filled
with granulations ; it soon afterwards healed,
and the man recovered with a good use of the
limb.

\ *

Yours, &c«

JAMES LYNN.

CASE III.

I attended a compound fracture of the ancle-
joint, in the year 1797, with Mr. Battlev, who
then practised as a surgeon in St. Paul’s Church-
yard, and is now a chemist and druggist in
Fore Street, of the first respectability and cha-
racter ; an account of which I shall give in the
words of Mr. Battley.

In the month of September, 1797, a gen-
tleman, lodging in Duke Street, Smitlrfield, in
a fit of insanity threw himself from a two-pair
of stairs window into the street, his feet first
reaching the ground. He got up without as-

114

ON COMPOUND DISLOCATIONS OF

sistance, knocked violently at the outer door of
the house, and ascended the stairs without the
least assistance, bolted the door after him, and
got into bed. He refused to open the door,
and it was obliged to be forced. A neighbour-
ing surgeon was sent for, who, on viewing the
case, proposed an immediate amputation, which
was not acceded to by his friends, but Mr.
Cooper and myself were requested to take
charge of the case. On examination there was
found a compound dislocation of the ancle-
joint ; the tibia was thrown on the inner side of
the foot, and when the finger was passed into
the wound the astragalus was discovered to be
shattered into a number of pieces ; the loose
and unconnected portions of bone were re-
moved and the tibia replaced, after which lint,
dipped in the oozing blood, was wrapped around
the lacerated parts, and the limb was placed on
its outer side, with the knee considerably bent.
The parts were ordered to be kept cool by the
frequent application of an evaporating lotion.
The patient remained as quiet as could be ex-
pected, under his state of mind, until the third
or fourth day, when a considerable inflamma-
tion appeared in the joint, and greatly increased
the previous irritable state of his constitution.
Leeches, fomentations, and poultices were ap-
plied to the limb, blood was taken from the
arm, and purgative medicines were given, and
afterwards saline medicines with sudorifics.
Extensive suppuration ensued, and continued
for six weeks or two months, when it began to
lessen and healthy granulations appeared on the
whole wounded surfaces , and about this time

THE ANCLE*

the state of his mind began to improve, and it
continued to amend as his leg advanced in re-
covery. At the end of four or five months
the suppurated parts had filled up, the joint
healed, and his mind recovered its natural tone.
At the end of nine months he returned to his
employment, but the ancle-joint was stiff. In
two years he had so far recovered as to walk
without the aid of a stick ; and at the end of
three or four years was able to pursue his avo-
cations nearly as well as at any former period of
his life.

RICHARD BATTLEYe

CASE IV.

On Compound Dislocation of the Tibia inwards.

I was sent for on the 1 1th of August, 1814,
by Mr. Richards, of Seal, in Kent, to visit Mr.
Knowles, a farmer, residing at TythamFarm,
aged 48, who had been thrown from his chaise
against the hinder wheel of a waggon, dislo-
cated his tibia inwards, and fractured both the
tibia and fibula.

/ . f •

Mr. Richards was immediately called to the
case, reduced the dislocation, and endeavoured
to heal the wound by adhesion. When I saw
him, which was ten days after the accident,
the wound wore a favourable aspect. The dis-
charge was abundant, but not in a degree to
excite alarm, and all I had to do was to praise
the judgment which had led to the preservation
of the limb, and to direct the continuance of
the means which had been employed for that
purpose.

i 2

- >

115

116

ON COMPOUND DISLOCATIONS OF

Before I ventured to state the case to the
public, I wrote to Mr. Richards, who informs
me that Mr. Knowles’s wound is perfectly healed,
and that he walks without the use of a stick.

CASE V.

For the following details I am obliged to Mr.
Rowley, apprentice to Mr. Chandler, surgeon
to St. Thomas’s Hospital.

DEAR SIR,

tn answer to your inquiries, I beg leave to
forward you the particulars of Elizabeth Chis-
nell’s case, who was admitted into St. Thomas’s
Hospital, Saturday, May 29th, 1819, with a com-
pound dislocation of the left ancle outwards,
occasioned by her slipping from the footpath
into the road-way. The wound communicating
with the joint was situated upon the outer part
of the leg, and was about four inches in extent,
through which the fibula projected two inches,
but it was not fractured ; the ligaments con-
necting the malleolus externus and the astraga-
lus were lacerated. From the inclination of the
sole of the foot inwards, the whole articulating
surface of the joint was so displaced as to allow
two fingers to pass readily across, when I found
the extremity of the tibia fractured. The parts
were easily returned to their original situation
by extending the foot, the leg having been first
bent upon the thigh. During the reduction
the integuments became confined between the
malleolus externus and astragalus, so as to re-
quire an incision upwards by the side of the
fibula, before it could be extricated ; but that

THE ANCLE.

117

being done, its lips were brought together by
four sutures, and straps of adhesive plaister.
Splints were applied, and the common applica-
tions to subdue the consequent inflammation
used.

June 1. The adhesive plaister and sutures
were removed, owing to the wound and adja-
cent soft parts around the ancle being in a state
of slough. Poultice of linseed meal were or-
dered to be used daily.

June 5. The sloughs are separated, the sore
is granulating, the discharge profuse ; a collec-
tion of matter has formed upon the inside of the
leg, which was discharged by puncture. The
Avound was ordered to be dressed, and a roller
was gently applied. The constitution during
this time was but little affected. Bark and
porter were ordered by Mr. Chandler.

August 7* The wounds are almost healed ;
the girl sits up daily, and in a few days she will
be allowed to walk. During the progress of
her cure the constitutional disturbance has been
trifling, indeed not more than in some favour-
able cases of simple fracture ; it may be also
well to observe that her bowels were regular
during the whole time, so as to preclude the
necessity of any laxative medicine, nor did she
take any other medicine but the bark.

I remain, &c. &c*

a. ROWLEY,

Dresser at St. Thomas's Hospital .

The following accident I was requested to
visit by Mr. Clarke, surgeon, in Great Turn-
stile, Lincoln’s Inn Fields ; and Mr. Clarke has

118

ON COMPOUND DISLOCATIONS OF

had the kindness to send me the following par-
ticulars.

CASE VL

Mr. George Carruthers, aged 22 years, had
a compound dislocation of the ancle-joint in-
wards, with fracture of the tibia, on the 6th of
October, 1817. The accident had happened
by the overturn of a stage-coach at Kilburn,
from whence he was brought to his house at
Lambeth. The end of the tibia projected
through the integuments of the inner ancle to
the extent of from two to three inches, and
the bone wras tightly embraced by the skin.
The tibia was fractured, only a small portion of
it remaining attached to the joint ; the bleeding
was stated to have been copious, but it had
subsided before Mr. Clarke saw him \ the fibula
was badly fractured.

For the reduction of the protruded parts it
became necessary to make an incision in the in-
teguments, to loosen them on the tibia ; and
when the bone was restored to its place simple
dressings were spread over the wound. A many-
tailed bandage, wetted with an evaporating lo-
tion and splints were applied, and the limb was
placed in the slightly bent position upon a quilted
pillow. Bleeding was had recourse to, gentle
purgatives given, and saline medicines. Symp-
toms of great constitutional excitement natu-
rally arose from so severe a local injury. Ab-
scesses formed on the leg, and some exfolia-
tions materially retarded the cicitrization of the
wound, and produced considerable exhaustion
of his strength. Openings were made into the

THE ANCLE,

119

abscesses., adhesive straps were placed over the
wounds, and lotions were applied on linen
under oiled silk, which preserved the parts con-
stantly wet. Bark and wine were given with
occasional aperients, Mr. Carruthers left town
on the 6th of October 1818, having then a
small opening on each side of the limb, and
suffering occasional pain, but his general health
had been good for some months previous. In
January last a considerable portion of bone
came away and the sore immediately healed
and has so continued ; he has been ever since
free from pain and is now in better health than
before the accident. He employs himself in
superintending a farm, around which he walks
with one crutch and a stick, but if the ground
be level, with a stick only, and the limb is be-
coming daily more and more useful.

THOMAS CLARKE,

CASE VII. and VIII.

To Mr. Somerville of the Stafford Infirmary
I am indebted for the following letter.

DEAR SIR,

I take shame to myself for not having an-
swered your obliging queries sooner, as to
the cases of compound dislocation of the ancle
which have fallen under my care ; but the fact
is, I wished to give you my answer in the most
authentic form, by sending you a transcript of
the cases from the minute books of the Infir-
mary; but after having caused the most diligent
search to be made for them, I have now the
mortification to learn, they are no where to be
found ; you will allow me therefore to plead this

120

ON COMPOUND DISLOCATIONS OF

circumstance as the real cause of my seeming
inattention to your wish, and at the same time
to offer it as an apology for the want of a more
detailed account. I have a distinct recollection
of two cases, though not of the manner in which
the accidents were produced. The first oc-
curred about fifteen years ago, the other a few
years later. They were both dislocated inwards
and were both discharged cured ; the one at
the end of the fifth, the latter not till the seventh
or eighth week. In the first case the wound,
which was lacerated so as to form a flap, healed
by the first intention ; in the latter it was kept
open by the discharge which was at first puru-
lent, afterwards limpid, but no untoward symp-
tom supervened during the cure. The treat-
ment in both cases was as follows.

After the reduction of the bone the patient
was placed upon his side with the limb in a bent
position ; no ligature was used ; but the lips of
the wound were nicely approximated and re-
tained in situ by straps of sticking plaister,
of ample length, yet not sufficient to encircle
the limb, lest they should, by causing undue
pressure on the supervening tension, excite too
much inflammation, and, in consequence, sup-
puration. To obviate, however, both tension
and inflammation as much as possible, a plaister,
spread moderately thick with Kirkland’s De-
fensative, was placed round and in easy contact
with the ancle, and over the whole a tailed
bandage was loosely applied. A brisk purgative
was given on the following morning, and low
diet was ordered till all danger of inflammation
was over. The adhesive plaister was removed
on the sepond or third day and was not renewed*

THE ANCLE.

121

but a pledget of mellilot digestive was placed
over the wound, and the defensitive bandage
applied as before. The subsequent treatment
consisted merely in the daily renewal of the
pledget and the proper adjustment of the plaister
and bandage, both of which were gradually drawn
tighter round the limb in proportion as the
danger of inflammation supervening became
lessened, and this with the view not only to give
stability to the joint, but also to facilitate the
progress of cicatrization.

The use of the plaister after the manner above
mentioned, may, at first, appear to you a singular
practice, but by being spread very thick, it
seldom requires a renewal during the period
of cure ; unless the discharge from the wound
should be so great as to render it necessary; but
if it should not, it will appear obvious that there
can be no necessity for disturbing or moving
the limb from the position in which it is first
placed ; a circumstance which I have ever
considered in cases both of compound disloca-
tions and compound fractures, of the highest
importance to facilitate the cure. It is com-
posed of two parts of Emp. Plumbi and one each
of oil, vinegar and chalk finely powdered ; and
is what 1 ever found a most powerful repellent
in all cases of violent local inflammation.

I am, Dear Sir,
very respectfully.

Your obliged and most obedient servant,

HENRY SOMERVILLE.

Stafford, Aug. 31, 1819.

122

ON COMPOUND DISLOCATIONS OF

The following case I received from Mr, Scare,
surgeon of Bishop’s Stortford.

CASE IX,

DEAR SIR,

John Plumb, who is the subject of the
following statement, was in the thirty- eighth
year of his age when his accident took place,
which was about seven years ago. He was in
the act of ascending a ladder with a sack of
oats on his shoulders, and had mounted ten feet
from the ground when the ladder slipped from
under him and he was precipitated to the
ground, lighting on Ins feet, but still sustaining
the sack of oats on his shoulders. I was pass-
ing about two hundred yards from the place at
the moment the accident took place, and was
consequently in immediate attendance. On the
removal of his stocking, I found that the tibia
and fibula had penetrated through the integu-
ments at the outer ancle, and were laying on
the outside of the foot ; the articulatory surface
of the astragalus had penetrated through the
integuments of the inner ancle, shewing on a
view of the case the foot nearly reversed ; the
bottom of the foot being placed where the side
of the foot is naturally situated; the wounds
through which the surfaces of the bone had pe-
netrated were free, which soon determined me
in the line of conduct I should pursue, viz. to
immediately reduce the joint to its natural situ-
ation with as little violence as possible, and
which was effected with much less difficulty than
I expected ; the wounds were brought close by
adhesive straps, the limb placed on its outer side,
and cloths applied constantly moistened with

THE ANCLE*

12$

acetated lead lotion ; he was then bled to about
sixteen ounces, a saline diaphoretic mixture was
given, and attention paid to his bowels; in
short the antiphlogistic plan was persevered in
with due regard to his constitutional powers, ab-
scesses took place which were opened in the
most favourable points, and after five and
twenty weeks the man was convalescent ; union
of the articulatory surfaces took place, the
wounds healed, and the man became enabled to
walk and to work ; he was not able to bear much
on his foot to work till about twelve months
after the accident, from which time he has con-
stantly been labouring in his situation with Mr.
Starkis, a gentleman of respectability of this
town, and continues to do so at this time.

It is my intention to send this man up to you,
that yop may have a full confirmation from him
of the accident, as well as from Mr. Cribb my pre-
sent assistant, who was present at the time of my
being called to him, being at that time with his
father, Mr. Cribb, surgeon of this town, whom
I consulted on the case at the time of the ac-
cident as well as during its continuance ; trust-
ing the statement and result may prove satisfac-
tory to your inquiry,

I am. Dear Sir,

your most obedient,

August 1 6th, 1819. r. T. SCAUR*

P.S. I hope Mr. Cribb and the man will be
with you at the beginning of the next week.

This man was sent to town, and I had an op-
portunity of witnessing the happy result of Mr.
Scarr’s skill and attention. A. C.

124

ON COMPOUND DISLOCATIONS OF

CASE X,

For the following most interesting case I am
indebted to a very excellent surgeon and inge-
nious man, Mr. Abbot, at Needham Market,
Suffolk. It admirably shews what may be ac-
complished in these cases, by extraordinary skill
and attention.

April 25, 1802, Mr. Robert Cutting, a
butcher by trade, age near seventy, corpulent,
very intemperate, and subject to gout from his
youth. In a dispute, when in a state of intoxi-
cation, he was thrown violently to the ground,
and suffered a compound dislocation of the tibia
at the ancle-joint ; the end of it was forced
through the integuments near four inches ; the
wound was large and half circular ; in the strug-
gle to stand erect, he rested his weight upon the
head of the bone, which was covered with sand
and dirt; the cavity of the articulating surface
of the joint was filled with blood and sand ; the
fibula fractured a few inches above the joint,
and the foot completely turned outwards ; in
this state he was placed in an open cart, full
four miles to his residence, Somersham, in Suf-
folk, about seven miles from Ipswich. It was
near five hours, from the time the accident took
place, before surgical assistance arrived, being
in the middle of a cold night. I attended with
a well-informed pupil of mine, Mr. John Jeffer-
son, who now, and has, resided many years in
Islington. A case so formidable, a large wound,
the connecting ligaments so lacerated, the sur-
faces of the articulating parts, from long expo-
sure and injured condition, led me to conclude.

f'HK ANCLE®

that ifc would be impossible to save the limb., and.
in a constitution so disordered ; however, no per-
suasion could prevail with a mind obstinate and
inflexible, he would not submit to amputation*
The surfaces were, carefully and expeditiously
as possible, made clean with warm water; the
reduction was easily accomplished, the lacerated
parts suitably placed, the edges of the wound
were nearly brought in apposition, without
stitches and adhesive plaisters ; the limb was
laid upon a proper sized thin board, excavated,
so as to take the form of the leg, with an open-
ing to receive the outer ancle ; this was well
padded, the foot part raised somewhat higher
than the leg ; plaits of lint wetted with the
tinctura benzoini composita, were placed over
the wound, which, in a few* hours, formed a
hard sealed cap, of a circumference that effec-
tually secluded the air ; a folded flannel band-
age was applied ; taking from the foot to the
knee, the leg was laid in a flexed position*
V* S. ^xij. A saline purge every two hours
until his bowels were relieved ; milk broth only
for his support, with common salt ; sixteen hours
after the dressing, his bowels had been properly
evacuated, he was tranquil; heat moderate; a
soft moisture was spread over the whole sur-
face ; pulse measured 86 ; and he had some
hours of refreshing sleep. April 27 th ; A little
active heat was raised ; sleep interrupted ;
pulse 96 ; surface moist ; darting uneasiness
about the ancle and foot; no thirst; bowels
kept cool, and the same support continued ;
common saline medicines were resorted to every

ON COMPOUND DISLOCATIONS OF

three hours. Upon unfolding the bandage*
some swelling appeared to surround the ancle ; a
little gleety discharge had escaped from beneath
the lower part of the dressing ; the inflammation
did not appear to be more than might be wished ;
lint, wetted with the tincture, was applied, so
as to prevent the escape of any discharge, al-
though a little distance from the wound, and to
seal the covering more secure ; half a dozen
leeches were applied a small distance from the
inflamed part ; they bled freely, and afforded
ease. April 29th; he passed a good night;
heat lessened ; free from thirst ; limb easy, and
free from tension ; and the inflammation about
the ancle abated. April 30th ; a quiet good
night, and every symptom appeared to promise
his safety being secured. May 2nd ; the pulse
had regained the natural standard ; upon ex-
amining the ancle, a small appearance of pus
escaped from the lower part of the cap or dress-
ing ; lint wetted in the same manner, to glue
the covering securely. From this time, my
visits became less frequent ; the tincture was
used whenever the surface of the cap appeared
to lose its hold. At the end of ten weeks he
was taken from his bed daily, and laid upon a
sofa. After the first stage of the interruptions,
healthy actions became established, and he be-
came perfectly well. Between the third and
fourth month, the cap or dressing was taken
from the ancle ; the wound was completely
cicatrised ; a small abraded surface appeared
over the cicatrix, occasioned by incrusted mat-
ter ; simple dressing in a few days rendered the

THE ANCLE.

place sound and well* During the time of the
Curative means, the factor was very trifling*
The thickening upon the wound was not more
than might have been expected upon one or any
muscular part ; the form of the joint was natu-
ral, and bore the appearance of a perfect state.
At the end of five months, he was allowed to go
on crutches, with the frequent placing his foot
upon the ground, and to allow of such a weight
or pressure as his feelings could admit. For
many months a long continued use of oil ob-
tained from the joints of animals, was had re-
course to, night and morning, for the space of
an hour every time, by patient rubbing; and to
please himself, he plunged his foot and ancle into
the paunch of an ox. With these means, an
imperfect motion in the joint was recovered, and
within twelve months he could walk without a
stick ; he pursued his occupation, and lived to
the age of 88. The last ten years he was able
to walk as well as ever he could. Mr. Jefferson
will be able to confirm this statement.

Since the case of Cutting, I have uniformly,
in a variety of compound fractures, followed the
curative plan of treatment by the first intention.
Mr. George Lynn, of Wcodbridge, my son-in-
law, a deserving character in his profession, and
the late Launcelot Davie, of Bungay, were pu-
pils of mine, and attended many cases with me
of a very formidable nature, successfully treated
by the same means. A case of a compound
fracture of the thigh, attended with considerable
comminutions of the femur, occasioned by a
waggon, loaded with twenty-five combs of bar-

128

ON COMPOUND DISLOCATIONS OP

ley, passing over it, perfectly recovered* by the
same treatment, within six months.

With the greatest esteem,

I have the honour to be,

Your very much obliged

and faithful Servant,

Needham Market , ROBERT ABBOTT,

Suffolk .

To Mr. Ransome, surgeon, at Manchester, I
am indebted for the following case.

CASE XL

DEAR FRIEND,

In reply to thy letter, requesting to know the
result of my experience in cases of compound
dislocation of the ancle-joint, I have great plea-
sure in stating the following case, which has
recently occurred. I take the liberty of briefly
describing it, as there were some circumstances
connected with it which did not afford the most
flattering prospect.

In the autumn of last year, a female, aged
about 45 years, of a strumous and leucophleg-
matic habit, attended with a troublesome cough
and occasional dyspnoea, fell from a high stool,
and pitching upon the left foot, caused a com-
pound dislocation of the ancle-joint; the foot
was luxated inwards ; the external malleolus
was fractured ; a lacerated wound extended half
round the joint, and exposed the protruding
portion of the malleolus, laying the cavity of the
joint so open as freely to admit the finger.

THE ANCLE.

129

and through which the synovial fluid escaped. I
removed a portion of detached bone, reduced
the dislocation, and brought the integuments to-
gether very slightly ; the limb was laid upon the
side, and kept constantly cool with the saturnine
lotion combined with the liq. ammon, acet. ; a
small opiate, and a demulcent mixture were
given at intervals. From the constitution of my
patient, I must confess I feared the most serious
consequences ; but I was happily mistaken ; but
little inflammation followed, the wound healed
without a copious suppuration, and she is now
perfectly recovered, and walks to considerable
distances. She was confined in a very small
room, and in a part of the town not very famous
for the purity and salubrity of its atmosphere.

I am, &c. &c.

T. A. RANSOME.

Manchester,

October 22, 1818.

Bengal Street, Canterbury .

MY DEAR SIR,

I take the earliest opportunity of complying
with your request, to furnish you with the re-
sult. of my observations on compound disloca-
tion of the ancle-joint.

You will perhaps think it singular, that this
division of Kent, which our hospital practice
embraces, should be so destitute of causes giv-
ing rise to accidents of this nature, that only
two cases have occurred, either in my private
practice, or at our hospital, during the last,
fifteen years, or to my coadjutor, Mr. Fitch ;
and as these are the only occurrences, 1 fear it

130

ON COMPOUND DISLOCATIONS OF

would be deemed presumptuous in me to form
an opinion upon the method to be adopted*
and the probable termination of the generality
of accidents of this nature* The favourable
result however of these two cases* admitted
under my care in the Kent and County Hospi-
tal* was so firmly impressed on my memory as to
confirm unequivocally the precepts you early
inculcated, to save the limb if possible in com-
pound dislocations of the ancle-joint. In ac-
complishing so desirable a point* the advantages
obtained in a country hospital will, I apprehend*
bear a greater proportion in the scale of success
than when the patient is placed in a crowded
infirmary of a large manufacturing town, or in
the metropolis, the constitution will in general
be less impaired by excess* poverty, and other
circumstances, whilst purity of air in large ven-
tilated wards materially contributes towards re-
covery, even be the injury to the joint exten-
sive ; we consequently can be permitted to take
greater latitude with our curative means upon
an injured joint, relying on the powers of nature,
without being under the immediate necessity of
anticipating the issue resulting from unfavour-
able habits, and in situations inimical to disease.

My notes furnish me only with the brief de-
tails of one case.

July 1818. A bricklayer, set. 36, of slender
make, but of good constitution and of sober
habits, fell from a height of between thirty and
forty feet upon loose materials for building, and
alighting upon his feet, he received a very se-
vere shock attended with comatose symptoms,
a fracture of the right thigh, a considerable

THE ANCLE*

131

contusion and laceration of the left ancle-joint,
accompanied with a dislocation of the bones
inwards, (that is, the tibia rested upon the inner
side the astragalus), a portion of the lower ex-
tremity of that bone fractured, and the fibula
was broken about three inches above the malleo-
lus externus, and the surrounding ligaments of
the joint were lacerated, but little difficulty was
found in reducing the dislocation and in replacing
the fractured bones ; but in consequence of the
violent injury done to the joint, it became a
question on the propriety of amputation. As
the man had enjoyed uninterrupted health, and
was of that constitution and habit least liable to
the attack of inflammatory affection, I ventured
to give a chance of saving the limb. An union
by the first intention of the external wound, as
far as practicable, was attempted, and the limb
laid in the most convenient, yet relaxed and
easy posture. Evaporating lotions were applied,
and the strictest antiphlogistic system enjoined.

Considerable inflammatory symptoms ensued,
with a copious discharge of synovial fluid ; the
limb and joint were much swollen, and it be-
came necessary to vary the applications to warm
spirituous and opiate fomentations and poul-
tices, which appeared more genial to the pa-
tient’s feeling, and were therefore continued.
A disposition of the contused parts to gangrene
appearing, muriatic acid was added to the ca-
taplasm, and the medicines were changed ac-
cording to the effect produced on the constitu-
tion by symptomatic irritation, and accruing
from the discharge. Soon after the application
of the muriatic acid the disposition to gangrene

K 2

132

ON COMPOUND DISLOCATIONS OF

ceased j (and from this medicine I have often
derived, in similar states, great advantage.)
After the first fortnight my hopes of saving the
limb were confirmed by the pain and swelling
subsiding, and the constitutional symptoms
being less violent, the colour of the discharge
improving, with less synovia, and granulations
arising around the wound. The man continued
gradually to improve till about the tenth week,
when the wound was nearly healed. This man
was discharged in fourteen weeks quite well,
although with rather an unsightly and partial
stiff joint.

The other case, of which I have no notes,
was also a compound dislocation of the ancle-
joint, but without the degree of injury the
above had sustained ; he was also discharged
cured.

I have now to apologize for trespassing upon
your time, in the attempt to give you the de-
tails of cases that might have been interesting
if not so cursorily drawn ; but as my notes were
only penned to furnish me with hints for the
future, from the distance of time the minutes
have escaped my memory, and I doubt they
are too inaccurate and too inconclusive to
afford you any information ; but the occasion
serves me as a pretext for assuring you how
much

I remain.

My Dear Sir,

Your very faithful and obliged Servant,

W. CHANDLER.

THE ANCLE.

133

< Royal Naval Hospital, Plymouth ,

August II, 1819.

MY DEAR SIR,

In answerto your letter inquiringof me whether
I have had any cases of compound dislocation of
the ancle-joint, with their treatment and their
result, I beg leave to acquaint you that several
of the above nature have fallen under my care
and observation during the eight years I served
as an assistant-surgeon, and the sixteen years I
have been the first surgeon of this hospital, nearly
the whole of which period the country was en-
gaged in active naval warfare, and consequently
this hospital was in the constant receipt of im-
portant surgical cases \ and I have also wit-
nessed a few more from other causes. The re-
sult of my observations has been, that in cases
of compound dislocations of the ancle-joint
there is not only a chance of saving the limb,
but of that limb being at a future time useful.
The dislocated bones should be replaced in
their situation with as little violence and injury
as possible to the surrounding parts ; and should
any difficulty arise in returning the bones, from
the smallness of the wound, I freely enlarge it
with a scalpel. After they are replaced, I lay
the limb perfectly extended on very soft cush-
ions of lint arranged on three pillows, the cen-
tre one reaching the length of the leg, the up-
per one crossing under the ham and inferior
part of the thigh, and the lower one across un-
der the heel, having previously placed on these
pillows a fine sheet, folded so often that when
its edges are turned in it might protect the
limb from the pressure of the splints $ under

♦

134

ON COMPOUND DISLOCATIONS OF

this sheet are laid several slips of calico about
eighteen inches long and three broad. When
the limb is thus comfortably placed, taking
care to fill up every hollow with lint, I draw
the edges of the lacerated integuments as near
together as they can be brought by the gentlest
means, retaining them with small slips of adhe-
sive plaister, and cover this with pledgets of soft
lint ; this done, I direct the foot to be kept
very steady, whilst I ultimately place the slips
of calico already described over the whole
length of the extremity, draw up the edges
of the sheet, and apply of each side of the
leg, outside of all, a very broad long splint of
common deal, and so long as to reach at least
three inches below the foot and as far above the
knee-joint, these splints being well covered with
lint, and then to be so secured as to afford
support (but no pressure) to the whole of
the leg and foot, the breadth of the splint ma-
terially contributing to the latter purpose, and
allowing the tape to pass around the limb with-
out injury ; the foot ought also to be prevented
dropping or altering the least its position, by
passing a broad tape through a hole in the lower
ends of the splints, which tape is to be tied,
securing between it the sole of the foot, which
will effectually keep it up, further securing it
by a stirrup bandage ; when every thing is
thus accomplished, the foot and leg arc di-
rected to be kept constantly wet with cold
water, taking care not to sponge it immedi-
ately over the wound. The subsequent treat-
ment of the patient, must depend upon the
symptoms which arise. This is the plan pur-

THE ANCLE*

135

sued by me, in those cases where there is a
probability of saving the limb. I have seen
more than one case, where, after great per-
severance and risk, the limb has been saved,
but when the wounds were all healed, found
to be of very little or no use ; as an example,
a man who had had a compound dislocation
of the ancle in the West Indies, from whence
he was sent to England as an invalid, became
my patient in this hospital, and when received,
a period of thirteen months from the accident,
had the whole of the lower head of the tibia
(although in its proper situation) exposed,
black, and carious, which at the end of a year
and a half came away more than three inches
in length, and at the expiration of three years
and a half from the injury, quitted the hospital
with the wound healed but with a shortened,
deformed, and anchylosed leg, liable to break
out on the slightest injury. The great point
to be decided on, however, in these accidents
is, in what cases the surgeon is justified in
attempting to save the limb, and in what cases
immediate amputation is necessary. From all
I have seen, I should not hesitate the immediate
removal of the limb, where the lower heads of
the tibia and fibula are very much shattered ;
where, together with the compound dislocation
of' these bones, some of the tarsal bones are
displaced and injured; where any large vessels
are divided and cannot be secured, without
extensive enlargement of the wound and dis-
turbance of the soft parts ; where the common
integuments -with the neighbouring tendons
and muscles are considerably torn ; where the

a/ 7

136

ON COMPOUND DISLOCATIONS OF

protruded tibia cannot by any means be re-
duced; where the constitution of the patient
is enfeebled at the time of the accident, and
not likely to endure pain, discharge, and length
of confinement.

I have a fine specimen of injury done to the
tibia, fibula, and tarsal bones, from a compound
dislocation, producing amputation ten months
after the accident, which occurred in the Me-
diterranean ; it is very much at your service to
see or copy, but must beg of you to have the
goodness to return it, and as it forms part of
a collection of bones, making by me for the
last twenty years,

I am, &c. &c.

STEPHEN L. HAMMICK.

1 beg Mr. Hammick to accept my thanks for
his excellent letter.

The following case shews, that under the
most unfavourable circumstances, these injuries
are not destructive to life in persons of good
constitutions.

Winchester, August 1st, 1819.

MY DEAR SIR,

In answer to your inquiries of my practice in
compound dislocations of the ancle-joint, I can
only say, that in almost every case that I have
witnessed, the general injury has been so great
as to require amputation. I do not recollect
but one cas^ which was not obliged to submit,
and that was a patient at a distance, whom I
was called to by a neighbouring practitioner.

THE ANCLE.

about five weeks after the accident, to use his
own words “ to reduce a dislocation of the
ancle, as he had reduced the fracture of the
fibula.” I saw the patient, but the fractured
fibula was so firmly united, that the case was
obliged to remain, the compound dislocation
gradually got well, if you can call the greatest
deformity I ever saw, well ; however no bad
symptoms arose, and I am persuaded, had
the dislocation been reduced, that the case
would have terminated in a most satisfactory
manner.

I had a case of compound fracture of the
elbow-joint, in the person of Dr. Wool, now
head master of Rugbjy which did well without
leaving any perceptible degree of stiffness.

I remain, my Dear Sir,

Yours very truly,

W. WICKHAM.

28, Park Street, Bristol,
Oct. 20, 1818.

MY DEAR SIR,

During the twenty-two years I have been sur-
geon to the Bristol Infirmary, and I believe
during my apprenticeship there, making in all
nearly thirty years, it has been our invariable
practice to endeavour to save the limb, in cases
of compound dislocation of the ancle, unless
where the chance was done away by some con-
comitant injuries or circumstances, but as a
general rule it was always adhered to, and this
would not have happened unless the great ma«

ON COMPOUND DISLOCATIONS OF

jority of cases had done well. We save the
limb in private practice almost invariably, unless
in very bad cases indeed.

I am,

My Dear Sir, &c. &c.

II. SMITH.

There is another mode of treatment in these
Sawing off accidents, which consists in sawing off the
the honest extremity of the tibia, before the bone is re-
turned into its natural situation, and the reasons
which may be assigned for pursuing this prac-
tice are as follow.

First - — That there is in some cases much

Difficult difficulty in reducing the tibia, and that great
reduction. vj0jence muS£ employed to effect it.

Secondly— The extremity of the bone is often
Oblique broken obliquely, so that when reduced it will
not remain upon the astragalus, but when the
point is removed by the saw, it rests without
difficulty upon the astragalus.

Spasms. Thirdly — The spasmodic contractions of the

muscles are much diminished, by shortening
the bone, as they are all thrown into a state of
relaxation by it ; whereas when the bone is re-
duced by violence, when the saw has not been
used, the spasm of the limb will be sometimes
very violent.

Local irri- Fourthly — Tli c local irritation is much di-

minished". miuished by the greater ease with which
adhesion is produced, both of the sawn ex-
tremity of the bone to the parts to which it is

THE ANCLE.

applied, for it is a mistake to suppose that the
sawn end of the bone will not adhere, as the
contrary is seen in amputation, in sawing off a
bone in exostosis, and in the union by adhesion
of compound fractures ; and that adhesive
matter can be thrown out upon cartilaginous
surfaces, is known to every person who has
dissected a diseased joint ; thus then the end
of the tibia adheres to the surface of the astra-
galus.

Fifthly — When suppuration does occur it is
rendered much less, and a considerable part of
the ulcerative process is prevented by the car-
tilage being mechanically removed, for nearly
half the articular surface of the joint no longer
remains. Cseteris paribus ; therefore the case is
sooner well.

Sixthly — The constitutional irritation is very
much lessened, both by the suppurative and ul-
cerative process being diminished, and the ease
with which the parts are restored. In the cases
which I have had an opportunity of seeing,
there was not more irritative fever than in the
mildest cases of compound fracture.

Seventhly — It has been found that in cases in
which the extremities of the bones forming the
joint have been broken into small pieces, and
have been removed by the finger, that the irri-
tation has suffered less, and the case more
quickly recovered than when the bone has been
returned whole.

Eighthly — I have known no case of death when
the extremities of the bones have been sawn off,
although I shall have occasion to mention some

139

Suppura-
tion and ul-
ceration
lessened.

Less consti-
tutional
irritation.

Bones shat-
tered.

No case of
death.

140

ON COMPOUND DISLOCATIONS OF

Objections j

liirife

shorter.

Anchylosis.

Each mode
useful.

in which the cases terminated fatally when this
was not done.

The objections which may be made to this
mode of treatment are, that the limb becomes
somewhat shorter by the removal of the cartila-
ginous extremity of the bone ; but this I do not
think an objection of any considerable weight
if the danger of the case is, as I believe, les-
sened by it, for the diminished length, which is
very slight, is easily supplied by a shoe made a
little thicker than usual.

The other objection is, that the joint becomes
necessarily anchylosed. I doubt very much the
truth of that objection, as in two instances I
have seen the motion of the part remains ; but
even when the joint becomes anchylosed, as it
is liable to do in each mode of treatment, still
the motion of the tarsal bones becomes so much
increased as to be a substitute for that of the
ancle ; and the patient walks with much less
halt than would be conjectured, and has a very
useful limb.

It is not my intention however to advocate
either mode of treatment to the exclusion of
the other, but to state the reasons which may
be justly assigned for the occasional adoption
of either. It is only by a comparison of the
different results of varied practice, that a safe
conclusion can be drawn ; and from what I have
had an opportunity of observing in my own
practice, and of learning from that of my friends,
I feel disposed to recommend to those whose
minds are not settled upon the subject, not to
hastily determine against either treatment in

THE ANCLE,

the different cases of this injury, as, from each
mode, under varied circumstances, a strong and
useful limb has been saved without any additional
risk being incurred to the life of the patient.

If the dislocation can be easily reduced with-
out sawing off the end of the bone; if it be not
so obliquely broken, but that it remains firmly
placed upon the astragalus when reduced ; if
the end of the bone be not shattered, for then
the small loose pieces of bone should be re-
moved, and the surface of the bone be smoothed
by the saw ; if the patient be not excessively
irritable, so as to occasion the muscles to be
thrown into violent spasmodic actions in the
attempt at reduction, and which leads to subse-
quent displacement when the limb has been
reduced. Under such circumstances the bones
should be at once returned into their places, and
by the adhesive inflammation the parts should
be united ; but rather than amputate the limb,
if the above circumstances were present, I should
certainly saw off the ends of the bones.

I shall now proceed to state the cases which
I have myself had an opportunity of witnessing,
and some which have been given me by my
friends, and leave the reader to judge of the
propriety of the advice I have given,

CASE I.

On Compound Dislocation of the Tibia outwards ,

at the Ancle- Joint .

I was sent for to Guy’s Hospital, to see Na-
thaniel Taylor, aged 13 years, and was directed

Cases la
u hieh the
one or the
other
should be
employed.

Cases.

142

ON COMPOUND DISLOCATIONS OP

to bring my amputating instruments with me*
as I was informed the boy had so bad a disloca-
tion of the ancle, that the limb could not be
saved.

As soon as I reached the hospital, I ordered
the patient into the operating theatre ; and
making inquiries into the cause and nature of
the accident, I found as follows : — The injury
had been occasioned by a boat falling upon
the leg. A large wound was seen at the outer
ancle, through which the tibia and a fractured
extremity of the fibula projected ; one inch of
the malleolus externus remained attached to the
astragalus by its natural ligaments ; the foot
was turned inwards, so as to be able to be made
to touch the inner side of the leg ; and from the
muscles being no longer on the stretch, the foot
was very loose and pendulous. I tried to reduce
the limb, but found that the bone could only by
great violence be brought on the astragalus, and
that it immediately slipped from its place. The
case was, therefore, as regarded the state of the
parts, the most unfavourable possible ; and those
around me urged an immediate amputation ;
but seeing the youth, and the character of health
which the boy bore, I thought I should not be jus-
tified in dooming him probably to a life of mendi-
city, and I determined to try to preserve the limb.
Finding that the lower end of the fibula, although
still connected by ligament, was very loose and
moveable, I removed it with the scalpel ; I then
sawed off half an inch of the lower extremity
of the tibia. When these operations had been
accomplished with the greatest care, I reduced
the bones, and they maintained their situation,

THE ANCLE®

&s there was Ho force of muscular action upon
them, on account of the shortening of the bones*
Lint, wetted with the person’s blood, was then
applied, with adhesive plaisters over it, and the
leg was put in splints, and placed on the heel.
Scarcely any constitutional irritation occurred ;
the wound and ancle-joint secreted but little
matter, and gradually healed* On the 17th day
an abscess shewed itself on the tibia, which was
suffered to burst, as it affected his constitution
but little. For two months he was allowed to
sit up and use his crutches. In twelve weeks
the wound was healed, and the boy able to bear
on his foot; and at the end of four months he
walked well. I used to have inconceivable
pleasure in seeing this boy walk before the
students, at my desire, from one end of the
ward to the other, four months after the acci-
dent, with very little lameness. There seemed
to be some motion at the ancle, but the tarsal
bones soon acquired sufficient mobility to give
to the foot so much play as to prevent the
appearance of stiffness, which a partially an-
chylosed state of the ancle would otherwise have
produced.

CASE XL

Compound Dislocation of the Ancle inwards .

— — W., Esq. aged 40, on December 1 1th,
1818, jumped out of his one-horse chaise, alarm-
ed by the horse’s kicking. He fell, and when
he attempted to rise, found his left ancle dis!o«

144

ON COMPOUND DISLOCATIONS OF

cated, and the bone projecting through the skin,
Mr. Mackinder, surgeon, brought him to the
house of his father-in-law, in London, where
Mr. Jones, of Mount Street, and myself, at-
tended him.

Upon examination of the part, I found the
tibia projecting at the inner ancle through the
integuments, which were nipped under the pro-
jecting bone into the joint; the foot was loose
and pendulous, and very much thrown out-
wards. Having prepared several pieces of linen
to form a many-tailed bandage, and procured
pillows and splints, he was placed on a bed on
his left side, and an attempt made to reduce the
bone; but finding that a most powerful extension
must be made, hearing from Mr. Jones that Mr.
W. was of a most irritable constitution, and
finding that the integuments must be cut down
opposite to the joint, so as to lessen the proba-
bility of an easy adhesion of the wound, which
was placed one inch and an half above the arti-
culation, I sawed off the end of the tibia, and the
bone most easily returned into its natural situa-
tion,in which it remained without difficulty. The
edges of the wound were brought together by a
fine thread, so as to be very closely adapted to
each other, and lint dipped in blood was ap-
plied over the wound ; the many-tailed band-
age was used ; the limb was placed on its
outer side, with the knee bent nearly at right
angles with the thigh, and splints were applied.
The leg was ordered to be kept constantly wet
with the liq. plumbi. f. acetat. diiutus, §v. and
spir. vini. ji. ; a dose of opium was given him.

THE ANCLEe

and ten ounces of blood were taken from his
arm. In the evening more opium was given
him , and a dose of infusion of senna and sul-
phate of magnesia, was ordered for the morning.

Dec. 12.— As the limb felt hot, the upper
splint was removed, its pressure being somewhat
painful, and it prevented free evaporation $
opium was ordered at night.

Dec . 13.» — The foot was vesicated; he had
chilliness succeeded by heat; slight tension of
the leg, and some pain for three hours. His
mind was much agitated by seeing his children.

Dec. 14.— The limb was less inflamed, and he
had scarcely any constitutional irritation.

Dec. 15.— A slight discharge of serum mixed
with red particles from the wound ; some pain
in the foot and leg, but no irritative fever.

Dec. 1 6.—' There was more discharge and some
air passed from the wound ; a poultice was ap-
plied, and a generous diet allowed, as his sto-
mach, naturally weak, had become very flatu-
lent ; pulse 90*

Dec. 17.— A fomentation and poultice applied.

Dec. IS. — The discharge becoming purulent ;
but as his stomach was deranged, Dr. Pemberton
saw him, who ordered him hyoscyamus with the
mistura camphor in the day, and opium at night.

From this time to the 7th of January, the dis-
charge from the limb was copious, but it then be-
gan to lessen ; and when the leg was examined on
the 12th of January, it had become firm ; a small
wound remained, on which the granulations
were prominent. In the first week in February
he was allowed to get upon his sofa, the limb
being now firm, and only a small wound remain-

146

ON COMPOUND DISLOCATIONS OP

ing, from which an exfoliation will occur, as the
bone can be felt bare.

In August I saw him ; the wound still re-
mained open, nnd the portion of bone had not
separated.

This gentleman, with the worst constitution,
as regarded the state of his stomach, did not
suffer more, and, indeed, not so much irritation,
as a compound fracture usually produces.

CASE III.

Mr. Charles AveriH, dresser to Mr. Forster,
surgeon of Guy’s Hospital, has had the kindness
to send me the following particulars of a case,
the progress of which I often witnessed with
pleasure.

John Williams, sailor, set. 38, a very robust
man, was brought into Guy’s Hospital, under the
care of Mr. Forster, August 9th, 1819, at four
o’clock in the morning, with a compound dislo-
cation of the right ancle inwards, and consider-
able injury to the left, occasioned by his falling
from a height of about twenty -six feet, in endea-
vouring to escape from the Borough Compter,
in which he was imprisoned. On examining
the injured part, I found the tibia protruding
three inches through a large transverse wound
of four inches in extent, and resting on the inner
side of the os calcis ; the cartilaginous surface
of the astragalus could be readily felt on passing
my finger into the wound; the fibula was broken.
I first sawed off the whole of the cartilaginous end
of the tibia, when the bone was easily replaced,
the edges of the wound were then brought as

THE ANCLE®

147

much in contact as possible ; lint dipped in blood
was applied, and over it straps of adhesive plais-
ter ; the foot and leg were wrapped in cloths wet
with an acetate of lead lotion, and the limb laid on
its side. He complained of great pain in the left
leg, which was very much swollen all round the
ancle ; ten leeches were applied to it, and after-
wards the liquor plumbi subacetatis dilutus, which
relieved the pain ; thirty drops of laudanum were
given, and he remained easy. The following day
sixteen ounces of blood were taken from him, and
five grains of calomel given. On the 12th, the
dressings were removed, the wound looked welk
On the 17th, suppuration had commenced, and
the discharge having rather a foetid smell, the
nitric acid lotion was applied*. September 2nd,
the matter gravitating to the outer side of the
leg, an opening was made, by which it was dis-
charged, and adhesive plaister applied to the
original wound, which was healing fast ; the dis-
charge gradually diminished, and on the 21st of
September, six weeks from the accident, both
wounds were quite healed. He has not yet left
his bed. There is motion at the ancle ; the toe
turns out but very little, and does not point
downwards. He wears splints, and the strength
of the limb is daily increasing. When the sweh
ling of the left ancle diminished, a fracture of
the external malleolus was also there discovered*

CHARLES AVERILL®

October Ath, 1819.

* The nitric acid lotion is the best application with which I
am acquainted during the sloughing process. I order it in the
proportion of fifty drops of the acid to a quart of distilled
water, and apply it by linen covered with oiled silk.

A. C.

L 2

♦

148

ON COMPOUND DISLOCATIONS OF

For the following letter I am indebted to Dr*
Kerr, of Northampton, who, at the age of more
than eighty, still continues to practise his pro-
fession with all the ardor of youth, and with a
strength of intellect which has been seldom
surpassed.

NortliaiJiplon, July 28///, 1819.

MY DEAR SIR,

I have had the honour of your letter this
morning, respecting compound dislocation of
the ancle ; several such cases have fallen under
my care, and it has been uniformly my practice
to take off the lower extremity of the tibia,
and to lay the limb in a state of semiflexion
upon splints ; by this means a great deal of
painful extension, and the consequent high
degree of inflammation are avoided. The
splints I use are excavated wood, and much
wider than those in common use, with thick
moveable pads stuffed with wool. I keep the parts
constantly wetted with a solution of liquor am-
monias acetatis, without removing the bandage.
In my very early life, upwards of sixty years ago,
I have seen many attempts to reduce compound
dislocation without removing any part of the
tibia ; but, to the best of my recollection, they
all ended unfavourably, or, at least, in amputa-
tion. By the method which I have pursued, as
above mentioned, I have generally succeeded in
saving the foot, and a tolerable articulation.

I am, with much esteem,

My dear Sir,

Your obedient humble Servant,

WILLIAM KERR.

THE ANCLE*

1 49

To Dr. Rumsey, of Amersham, I am obliged
for the following interesting communication.

CASE IV.

Amersham .

DEAR SIR,

I have the pleasure of forwarding to you the
case of a compound dislocation of the ancle*
which came under my care many years ago* and
which had a fortunate termination, as the pa-
tient lived many years after the accident.

On the 21st of June, 1792, Mr. Tolson, aged
40 years, a respectable tradesman in New Bond
Street, Westminster, was thrown from a curricle
on Gerrard’s-cross Common, eight miles from
this place, in consequence of the horses taking
fright, and drawing the carriage with great ve-
locity against a tree. The injury he received
from this accident consisted in a compound dis-
location of the tibia and the fibula at the outer
ancle of the left leg, with a fracture of the as-
tragalus, (the superior half of which was attach-
ed to the dislocated bones of the leg,) and like-
wise (although, as we shall see, not immediately
noticed,) a simple fracture of the os femoris on
the same side. He was immediately conveyed
to a friend’s house on the common, where he
had the advantage of an airy healthy situation,
with every kind of domestic attention the family
could administer. I saw him about two hours
after the accident, and found the bones pro-
truding at the ancle through a very large wound,
with the foot turned inwards and upwards, and
the integuments beneath the wound exceedingly

150

ON COMPOUND DISLOCATIONS OF

confined by the dislocated bones which descend-
ed nearly to the bottom of the foot. A consi-
derable haemorrhage had taken place, but was
stopped by the spontaneous contraction of the
lacerated vessels.

From such a formidable accident in so large
a joint there appeared very little probability of
the patient’s recovery, without immediate am-
putation ; I therefore requested that a consult-
ation with some other surgeons might be expe-
ditiously held on the case, and expresses for
this purpose were accordingly sent to Mr. Pear-
son, surgeon, in London, and to my brother,
Mr. Henry Rumsey, surgeon, at Chesham iu
this county. While I was waiting for their ar-
rival, the patient requested me to examine his
thigh, when I plainly discovered an oblique
fracture of the os femoris at its superior part.
This additional evil appeared to me a great
obstacle to an amputation. My brother, when
he arrived, being of a similar opinion, I at-
tempted to reduce the fractured dislocated
joint into its proper situation. This I found
very difficult to effect without first separa-
ting that part of the astragalus which was
pendulous to the tibia, having its capsular liga-
ment lacerated one half way around the joint.
This portion of the astragalus consists of the
broad smooth head by which it is articulated to
the tibia ; of almost the whole of the inner and
outer sides of this head, by which it moves on
the inner and outer malleoli 5 and of about the
upper half of the posterior cavity on its under
surface, by which it is united to the os calcis ;
^o that the bone was divided nearly horizontally.

THE ANCLE*

151

and the part left behind consists of the lower
half of the last mentioned cavity, and of the
whole of the other or anterior cavity which
connects it with the os calcis ; and of the an-
terior portion or process by which it is articu-
lated to the os naviculare ; 1 therefore removed
it without hesitation, being persuaded that if it
had been practicable to reduce it into its origi-
nal situation, so large and moveable a portion
of bone would have been a source of pain and
irritation, and have rendered the cure more
difficult and uncertain, I then divided that
portion of the integuments of the foot which
was confined by the protruded end of the tibia,
which enabled me with ease to reduce it and
the fibula into their proper situation. I applied
some dossils of lint dipped in tincture of opium
to the wound, and covered the whole with a
poultice of stale beer and oatmeal. We now
reduced the fractured femur and placed the
limb in a bent position, expecting that our
greatest success would be in procuring a com-
plete anchylosis, the failure of which I con«
eluded would leave a useless foot. The under
splinter was a firm excavated piece of deal,
of the shape of the leg and foot, with a hole
opposite the ancle. Mr. Pearson arrived in the
evening, and approved of the preceding treat-
ment, giving it as his opinion that it would be
safer to attempt the preservation of the limb
than to amputate under such complicated cir-
cumstances. The wound was concealed as
much as possible from the external air, and the
cataplasm renewed no oftener than the dis*
charge rendered necessary.

15 2

ON COMPOUND DISLOCATIONS OF

22d. The preceding night had been very
painful, with delirium and vomiting ; the pulse
was full and frequent ; I took away ten ounces
of blood, and gave potassse tartras. ; and manna
in doses sufficient to procure stools. A com-
mon saline draught, with antimonial wine and
tincture of opium, was given every four hours,
and a fuller dose of tincture of opium at bed-
time.

23d. The vomiting continued ; the ancle and
thigh had been less painful through the night ;
the saline draughts were continued, but with-
out the antimony, on account of the vomiting $
during this period the antiphlogistic regimen
was strictly adhered to.

24th. The night had been tolerable ; the
vomiting had ceased ; the pulse was softer ; the
saline draughts were continued with the opiate
at bed-time ; this evening the leg was very pain-
ful ; he passed a pretty good night ; a discharge
from the wound now commenced, and the ten-
sion of the muscles of the thigh began to di-
minish.

26th and 27th. The same treatment was con-
tinued. The discharge increased, and the ten-
sion of the thigh still more abated.

28th. The ancle was much swelled and in-
flamed ; I therefore exchanged the beer grounds
in the cataplasm for the liquor plumbi subace-
tatis dilutus. The patient had this day much
pain in the bowels from flatulence ; from which
circumstance, and that of the discharge being
very thin, it was judged expedient to vary his
mode of living, and likewise his medicines.

29th. He was allowed a small portion of ani-

THE ANCLE*

153

mal food, some table-beer, and some port wine ;
and he took the bark liberally both in substance
and decoction. This change of treatment agreed
with him perfectly well. At this time I found
it necessary to alter the position of the limb
on account of the pressure on the wound, oc-
casioned by its laying in the bent position, and
the pain it gave in turning to dress it, which,
from the copious discharge, there was now a
necessity for doing night and morning. I
therefore placed it on the heel, using the com-
mon deal flexible splint, of the length of the
limb, and confined it in a box, whose sides and
lower end let down ; the space between the
sides of the box and splint was filled with pieces
of flannel. By these means, and the use of
the eighteen tailed bandage, the dressings were
applied with very little disturbance to the leg,
whereby the patient escaped much pain. The
upper end of the box under the ham was raised,
which gave the muscles some degree of flexion,
and at the same time was favourable to the dis-
charge. The foot having a tendency to fall
inward, and the end of the fibula to protrude
through the wound, it required great attention
to prevent the deformity the neglect of these
circumstances might have occasioned. The
mode of prevention I adopted, and which
proved successful, consisted in employing a
number of small deal wedges, about six inches
long, two broad, and a quarter of an inch
thick ; as many of these as were found suffi-
cient were placed opposite the inside of the
foot, between it and the side of the box; others
in the same manner on the outer side of the

154

ON COMPOUND DISLOCATIONS OF

calf of the leg ; by which means the limb was
kept steady, and by placing the heel easy and
rather hollow, none of the usual evils arising
from pressure on the heel occurred.

30th. The bark agreed very well ; the opiate
was continued at bed-time ; the discharge was
great, but more purulent ; the pulse was be-
come softer and less frequent ; and the urine,
which had hitherto been clear and very high-
coloured, was now turbid ; the pain and inflam-
mation being much diminished, the cataplasm
was discontinued, and the wound dressed with
dry lint with a pledget of cerat. plumbi super-
acetatis over it, and a moderate compression was
made by means of a bandage. From this period
the wound progressively mended ; the discharge
diminished ; granulations formed ; and the sur-
rounding skin began to heal. The use of the
bark and of the opiate was continued till the
beginning of August. About the end of July
the progress of the cure was retarded by matter
collected under the integuments, above the
inner ancle, which on pressure came out at the
wound. After trying the effects of permanent
pressure, for the prevention of this deposit, in
vain, I made an incision into the cavity, and
filled it with dry lint, to produce inflammation
on its internal surface, which consolidated it,
and the wound became perfectly cicatrised
by the middle of September, without any exfo-
liation of bone larger than the head of a pin
having taken place. The fracture of the femur
went on very well, excepting that the obliquity
of it, with the impossibility of producing a per-
manent extension on account of the leg, occa-

THE ANCLE.

15$

sioned a degree of curvature which it otherwise
would not have had. The limb gradually ac-
quired strength, and the patient is able to walk
very well with only the aid of a small stick, and
even this assistance he will probably not require
long. There is no anchylosis to render the
ancle immoveable ; but a sufficient firmness
has been produced in the surrounding parts by
the long continued inflammation to assist in
the formation of an artificial joint, which pos-
sesses a degree of motion nearly equal to the
natural one.

For the following most interesting case, I
am indebted to Mr. Hicks of Baldoek.

CASE V.

Baldoek, August 10, 1819.

MY DEAR SIR,

In the absence of my son, I beg leave to for-
ward you the following account of a case of
compound dislocation of the ancle.

Case of John Curwan. — Early in the morn-
ing of November 10, 1812, the Stamford coach,
from the guard neglecting to chain the wheel,
ran with great velocity down the hill a mile
below Baldoek, and fell on its side a little before
it reached the foot of the hill ; in its fall the
side of the coach caught the coachman’s right
leg and turned the foot upon the outside of the
leg, by which the tibia became dislocated on
the inner side ; the tibia and fibula protruded
through the integuments about four inches ;
the oblong end of the fibula was fractured and

156

ON COMPOUND DISLOCATIONS OF

several small portions of it remained within the
integuments, the end of the tibia had some
small portions chipped off it, appearing as if it
had been ground by the side of the coach ; in
this state he was brought to Baldock, with his foot
dangling to his leg ; the wound was very large,
so much so that the foot appeared almost sepa-
rated from the leg, the ends of the bone were
covered with dirt.

There not being the least chance of success
in returning the tibia and fibula within the in-
teguments, in this state, and as the patient was
desirous of having his leg preserved if possible,
which I likewise was very anxious to try, I
judged it prudent to saw off the ends of the
tibia and fibula, the foot at the same time laying
on a pillow below the leg ; after removing the
ends of the tibia and fibula, I searched for the
fractured portions of the fibula left within the
integuments, by introducing the fore-finger of
my right hand into the wound, and found its
external malleolus fractured into several small
pieces, but still adhering by its ligaments to the
astragalus. Being fearful these shivered portions
might be deprived of the properties of life, and
if so, would produce much mischief, I resolved
to dissect them out by means of a bistoury,
through the wound. Having thus removed
every fragment of the fibula, and rendered the
ends of the tibia and fibula perfectly smooth by
means of a saw, not only removing their frac-
tured ends, but as high up as they were stripped
of their periosteum, about one inch and a half
in length, measuring from the malleolus inter-
ims, 1 then returned the remaining part of

THE ANCLE.

the tibia and fibula that had perforated the in-
teguments, placing it in a straight line with the
leg, the lacerated integuments I brought into
contact, and secured them by straps of adhesive
plaister ; the limb was then placed upon a soft
pillow, supported by Mr. Potts’ long splints
placed on the outside of the pillow and fastened
with tapes ; compression of soft linen cloth was
applied, and the leg kept constantly wet with
the diluted solution of the acetate of lead, and
the following draught was given for the first few
days, every four hours, and afterwards every six
or eight, with a regimen strictly antiphlogistic.

R Pulv. Ipecacuanhse. c. gr. vj.

Magnes. Sulphat. 5j.

Aquas Puras. 5ix.

— — Menthse. 5iij.

Spt. iEtheris Nitros. 5ss. M. Ft. Haust.

Through the whole of the cure the man went
on remarkably well, and had little symptoma-
tic fever ; pulse constantly below the natural
standard, between 60 and 70 ; skin soft and
moist ; the action of the intestines was regu-
larly kept up by the draughts ; the integuments
united by the first intention, without the least
secretion of pus. On the day seven weeks from
the accident, the patient was removed from
Baldock to his residence at Plewlington, and
did not require chirurgical aid afterwards. In
a few months after, he paid me a visit at Bal-
dock, walked perfectly well, and the leg was
very little shorter than the other. The last time
I saw him was by chance, in April, 1815, at the

158

ON COMPOUND DISLOCATIONS OF

Bell New Inn about three miles below Baldock,
where his coach stopped, and he descended and
ascended his box with great agility.

I am, my Dear Sir,

Yours most respecfully,

GEO. HICKS.

My friend and late dresser, Mr. Cooper of
Brentford, an ingenious surgeon and excellent
man, sent me the following valuable communi-
cation.

CASE VI.

Case of Com found Dislocation of the Ancle -
joint , by Mr, G. Cooper .

Thomas Smith, aged 36, by trade a painter*
whilst at work on the 28th of October, 1818,
fell with a ladder to the ground, when his leg
getting between two of its steps, the foot was
dislocated inwards. The fibula was broken five
inches above the joint, the tibia was fractured
from the ancle-joint longitudinally, about three
inches ; this small piece of tibia, three inches in
length, remained attached to the joint at the
inner malleolus, while an inch and a half of
the remaining portion of tibia, with the extre-
mity of the fibula, were thrust through an open-
ing in the integument, at, and rather anterior
to, the outer malleolus. I was passing at the
time, and attempted by very moderate extension
to reduce the dislocation ; this not succeeding,
and finding the integuments tucked under the
protruding portion of bone, with a scalpel I
dilated the wound anteriorly and posteriorly

THE ANCLE.

159

about half an inch, and then by means of a
metacarpal saw, removed rather more than an
inch of the tibia and a small portion of fibula.
The dislocation was now reduced without any
difficulty. The wound was closed by two liga-
tures and a few straps of adhesive plaister. The
patient was placed on a mattress with the limb
on the heel, enveloped in an eighteen tailed
bandage, which was applied just sufficiently
tight to give moderate support, without pro-
ducing or increasing tension ; on either side
was placed a splint, and the limb was kept con-
stantly cool by means of an evaporating lotion.

Subsequent to the operation and during the
whole of the night, there was some haemorrhagy
from the articular arteries, but not sufficient to
induce me to undo the limb in order to secure
the bleeding vessel, and I did not open it till
the 31st of October, the fourth day, when con-
siderable adhesion had taken place and the parts
looked better than I could have expected ; but
on the eighth day there was a line of separation
formed about five or six inches in circumfe-
rence ; the wound was now fomented, a linseed
meal poultice applied to it every six hours, and
the evaporating lotion was still applied to the
limb above, as far as the knee. On the thir-
teenth or fourteenth day, the slough came away,
and healthy granulations were observable, both
upon the integuments and also upon the extre-
mity of the tibia ; when these granulations be-
came exuberant, they were kept down by the
nitrate of silver, and the wound slightly dressed
either with Ungt. Cetacei or equal parts of
Ungtc liesinae and Cerat. Calaminae. In five

160

ON COMPOUND DISLOCATIONS OF

weeks the wound was perfectly healed, and the
union of the fractured portions of the tibia
went on so well, and the ossific deposit at the
joint became so firm, that on Christmas Day,
being fifty-eight days from the time of the ac-
cident, I found the man sitting at his table
dining with his family, and in three months he
was in the street on crutches. This patient had
repeatedly suffered much from colica pictonum,
bis digestive organs were unhealthy, and he was
a man of nervous temperament, all which I had
to discover after the accident. As early as the
third day he was very restless, on the fourth his
sensorium was much affected, and he was con-
stantly vomiting ; by the frequent administra-
tion, however, of the saline mixture in the act of
effervescence, his stomach was quieted. I ought
to have observed that, on the night of the acci-
dent, he took an opiate, and on the following
day I purged him ; but from the state of his
pulse, and from the degree of hasmorrhagy, I
did not find it requisite to take blood from the
arm. By the eighth day, his stomach being
tranquil, we were enabled to assist the separa-
tion of the slough, by invigorating the powers
of the system with bark and port wine, from
half a pint to a pint of which, with eight ounces
of the decoction cinchonas and opium, the
quantity of which was regulated by his state of
irritability, enabled him to support the immense
suppuration at the joint, which from this time
to the fourth week discharged most copiously.
I may here mention that I never observed on
the one hand the stimulating effects of opium,
and on the other its sedative, so strikingly ex-

THE ANCLE*

161

emplified as in this man, for if he did not take
quite enough to produce sleep, he was literally
mad, tearing the bed-clothes, swearing, praying,
singing, and making the oddest grimaces pos-
sible ; but if he had a full dose, which, by the
third week, was two drachms of laudanum, he
slept soundly and awoke refreshed ; and I be-
lieve from his extremely susceptible state, that
but for opium, which produced a directly seda-
tive effect upon his nervous system, he would
have sunk from constitutional irritation ; at the
end of the second week, his stomach being in a
fitter state for digestion, lie was allowed plenti-
fully of animal food and good beer, with which
and wine, bark and opium, continued for a
week or two, he perfectly recovered.

I am. Sir, he. he .

GEO. COOPER*

CASE VII.

Worcester , July 30, 1819.

DEAR SIR,

I have had no case of compound dislocation of
the ancle-joint under my care, since I have set-
tled in practice ; but my colleague, Mr. Sand-
ford, gives me the following information, which
I do myself the pleasure of transcribing.

A boy 15 years of age, was admitted into the
Worcester Infirmary with compound dislocation
of the ancle, the protruding portion of the tibia
was sawn off, the anterior tibial artery was taken
up, the limb placed on its outer side, the wound
dressed superficially, and the dressings retained

162

ON COMPOUND DISLOCATIONS OP

with a many tailed bandage, kept wet with the
liq. ammon. acet. Suppuration and granulation
came on kindly, the boy wore tin splints for a
length of time, and on his recovery had a slight
motion of the ancle-joint.

I am, my Dear Sir,

Yours very respectfully,

J. CARDEN®

P. S. My late master, Mr. Trye, had under
his care a case of compound luxation of the as-
tragalus, where he cut out the luxated bone,
and the patient had a good recovery, with a
tolerably useful foot. This is, I believe, a very
Tare case®

CASE VIII.

Sept. 1 , 1819.

MY DEAR SIR,

Some domestic events have delayed my reply
to your letter.

I remember six cases of compound disloca-
tion of the ancle-joint, four of which underwent
immediate amputation. In the two other cases
attempts were made to save the limbs and in
one with success. Most of these accidents were
produced by machinery, and the injury to the
joints and soft parts was so great as to render
all hopes of saving the limb vain.

In the limb that was not saved, though at-
tempted to be so, there was too much mischief
done, and after seven months’ trial, amputation

was performed.

THE ANCLE*

163

I was called to a fine young woman of eighteen
years of age, (who had been consulting me not
an hour before on the case of her father) and
who had fallen from her horse and suffered a
compound luxation of the ancle-joint externally .
The tibia and broken fibula protruded about an
inch and a half through the wound on the out-
side of the limb. I sent her to the hospital ,
and in consultation, proposed that a sufficient
quantity of the bones should be removed to
admit of restoration. I advised this attempt to
save the limb, from observing that the accident
took place by a heavy fall with the sole of the
foot to the ground, that it was unaccompanied
by contusions, or violence committed by a blow
or wrench, and that the patient was a very
healthy country girl. There had been consider-
able haemorrhage.

The extremities of the bones were removed ;
the reduction accomplished, and the limb sup-
ported by a tailed bandage, splints applied mo-
derately tight, and the bandages were directed
to be kept constantly soaked in a cold applica-
tion ; an opiate was given.

On the following day there had been consi-
derable haemorrhage, but the limb was not dis-
turbed. Great suppuration took place about
the joint, spread up the limb, and greatly re-
duced the patient, but she recovered. These
collections were never opened, which I should
have done early, and thus perhaps have pre-
vented that extent of suppuration which so
much reduced the patient.

Any further details I will give you if you
require them, on this as on all occasions, with
great pleasure, and I must hope that on all oc-

M 2

164

ON COMPOUND DISLOCATIONS OF

Gases re-
quiring am
putation.

Does not
always
succeed. '

casions you will make use of me, and now ac-
cept my apology for not answering yours before.

Very faithfully yours,

R. FLETCHER®

The following I received from my friend Dr.
Lynn.

CASE IX®

A man on board the Walmcr Castle East
Indiaman, in the year 1803, whilst the ship was
off the Cape of Good Hope, fell between decks,
and a cask of water rolled upon his ancle, pro-
ducing a compound dislocation of the end of
the tibia inwards. I sawed off the projecting
portion of the tibia, brought the parts as closely
as possible together, applied evaporating lotions
to the limb, and the man recovered without any
dangerous symptoms.

JAMES LYNN, M.D.

But still cases occur, in which the operation
of amputation will be rendered absolutely ne-
cessary, either to preserve the life of the pa-
tient, or to prevent his being doomed to the
constant necessity of using crutches on account
of the deformity and stiffness of the limb.

It seems to me, however, to be by much too
prevailing an opinion, that the amputation of the
limb is a sure means of preserving life, for when
this operation used to be more frequently per-
formed in our hospitals than it now is, for com-
pound dislocation of the ancle and compound
fracture of the leg, a considerable number died®

165

THE ANCLE.

Very lately a man at Tring had his foot torn off
by a threshing machine, and the limb was
obliged to be amputated at the usual place
below the knee. The operation was performed
by Mr. Firth, but the man died in the evening
of the 6th day.

The circumstances which I have known give
rise to this necessity are,

The advanced age of the Patient

Under great age the powers of the body be- Age,
come so much weakened, that the patient is
unable to bear the constitutional excitement
which the suppurative inflammation of the joint
produces, and as the operation of amputation
does not expose him to this process, it is better
to have recourse to it. However, I ought to
observe, that when in my lectures 1 have stated
what I have now advanced, the pupils have
flocked around me after lecture, and have told
me of cases of recovery even of very old per-
sons ; but in the practice of hospitals in this
extended city, very aged persons sink under
these accidents, if the limb be not amputated.

A very extensive lacerated wound will give rise Laceration,
to a necessity for this operation .

CASE X,

July 10th, 1806, Mr. Dudin, a gentleman re»
siding in Horslydown, Borough, jumped out of
his one-horse chair and dislocated the tibia in-
wards at the ancle through a large lacerated
wound, and a portion of the malleolus internus

166

ON COMPOUND DISLOCATIONS OF

Difficult

reduction.

Bones

shattered*

was broken off and remained attached to the
astragalus. The wound bled freely, and the
foot was loose and pendulous. I therefore felt
myself obliged to amputate the limb.

Mr. D. after this operation, proceeded in
every respect favourably, recovering without
any untoward symptom.

A difficulty in reducing the hones has been consi-
dered as a reason for amputation .

This circumstance, however, is rather a motive
for removing the extremities of the bones by
the saw, than for performing the operation of
amputation, after which, the reduction of the
tibia is easily effected, and an useful limb is
preserved to the patient.

The hones are sometimes extremely shattered .

If the lower extremity of the tibia be broken
into small pieces, the loose portions of bone
ought to be removed and the end of the tibia
be smoothed by a saw ; but if in addition to
this comminution, the lower extremity of the
tibia be obliquely broken, and a large loose
portion of bone be felt with the fingers, then it
will be proper to amputate ; also if the astra-
galus be broken, the portions of this bone
should be removed or they will separate by ul-
ceration, or occasion unnecessary local irrita-
tion. (See Dr. Lynn's and Dr. Rumsey’s cases.)
But if the end of the tibia and tarsal bones, as
the astragalus and calcis, are broken, then the
operation of amputation will be required. The
following case shews well the necessity for
amputation in such a state of parts.

THE ANCLE®

CASE XL

I was requested to see a lady, aged 34 years,
who on August the 9th, 1819, had, in a fit of
insanity, jumped out of a two pair of stairs
window and produced a compound dislocation
of the tibia and fibula at the outer ancle. I
met at the house Mr. Stephens, a surgeon re*
siding in Hunter Street, Brunswick Square,
who had been called immediately after the ac*
cident. As she appeared almost insensible, and
Mr. Stephens feared an injury to the brain, he
took away twelve ounces of blood. When he
examined the ancle he found the malleolus ex*
ternus of the fibula projecting through the
wound, but unbroken ; the tibia dislocated and
broken ; the foot very much turned inwards. He
extended the foot and thought that the bones had
exactly returned into their natural situation ;
adhesive plaister was applied upon the wound,
and its edges nicely adjusted. She was placed
on a mattrass with the limb upon the heel,
and with a splint on each side of the leg.
For seven days she complained of little pain,
and had but slight constitutional disturbance ;
on the day week from the accident, I was
requested to see her, and finding little local
or constitutional irritation, I recommended
that the limb should not be disturbed, and the
dressings were not removed.

On the 10th day from the accident, Mr. Ste-
phens finding her in more pain, examined the
wound, and found that it had not adhered.

168

ON COMPOUND DISLOCATIONS OF

On the 12th day a considerable discharge
issued from the wound.

On the 16th day, a slough had separated and
exposed the bones, which appeared shattered
and projecting. On this day I again saw her,
and upon examining the ancle, found the astra-
galus projecting and a portion of it broken, and
as the surrounding parts were dead, I removed
the projecting bone. Introducing my finger
into the wound as soon as the astragalus had
been separated, the tibia was found to be shat-
tered and the os calcis broken into many pieces.
As her pulse was 100 and small, and her strength
was failing, I immediately recommended her to
submit to the operation of amputation, to which
she consented.

On the Monday following the stump was
dressed by Mr. Stephens, and the greater part
was adhering.

Two of the ligatures separated on the 10th
day, and the other came away on the 16th
day.

Sept . 29. The stump was healed, excepting
about the size of the section of a pea, and she
has no complaint remaining excepting a sore
upon her back, and pain in the left foot.

It is proper to mention that she hurt her
spine and kidneys by the fall, so as to discharge
urine tinged with blood for three weeks after
the accident.

The other ancle also was most severely in-
jured, and she suffered exceedingly from pain
in it.

Upon examination of the limb, the tibia was
split up from the malleolus interims to the ex-

THE ANCLE*

169

tent of three inches : the fibula was unbroken ;
the astragalus was broken and detached ; the
os calcis was fractured into several pieces*

The Dislocation of the Tibia at the miter ancle Dislocation

outwards.

produces much more injury and danger than
that at the inner, and amputation will be more
frequently required for it, because both the
bones and soft parts suffer more than in the
dislocation inwards.

It sometimes happens that when the bone is replaced
it will not remain in its situation , and all the
symptoms of the injury become removed .

This circumstance arises from the tibia in the Oblique

dislocation outwards being obliquely broken,
and only a small portion of the articulating sun*
face remaining on the dislocated extremity of
the tibia, it will not rest on the tibia when it is
reduced. Mr. Andrews, of Stan more, and
Mr. Foote, of Edgeware, consulted me on the

f laciture
with

dislocatww.

following case.

CASE XII.

Mr. Andrews and Mr. Foote were sent for
on August the 9th, 1817, to the Hyde, six
miles from London, to visit Charles Tomlin, a
higgler, 48 years of age, who, falling from in-
toxication, had the wheel of his cart pass over
Ids left leg, which produced a protrusion of
the bones through the integuments at the outer
ancle. Mr. Andrews reduced the dislocation
in the evening of the accident. On the same
night Mr. Andrews and Mr. Foote visited him
again, and found his pulse very quick, and

I TO

ON COMPOUND DISLOCATIONS OF

spasms in the limb, which had again displaced
the bone. They gave him a large dose of opium?
and succeeded in reducing the bones.

On the 10th he had a very quick pulse, ac-
companied with strong spasms in the limb, but
not sufficiently severe to displace the bone.

On the 11th, I was requested by Mr. An-
drews and Mr. Foote, as 1 was going through
the village, to stop and see this man ; and as
soon as the bandages were removed a violent
spasm again threw the bones from the astraga-
lus, and all the efforts I could make would not
replace them. Seeing therefore no hope of the
man's recovering without the amputation of the
limb, I immediately proposed it, and he rea-
dily gave his consent.

For three or four days he had a great deal of
nervous irritation, which was most relieved by
occasional doses of opium and aether*

On the 18th, the stump was inflamed, and
in some parts sloughy, and on the 2 2d it bled,
but not profusely.

On the 25th a poultice was applied, and
from this time the appearance of the stump im-
proved, and he proceeded without interruption
in his recovery. In a month he returned to
his home at Bushey, a distance of seven miles.

Upon examination of the limb, I found the
cellular membrane around the ancle loaded
with extravasated blood ; the ligamentum an-
nulare tarsi was torn. The muscles were all
remaining whole, though some of them, as the
peronei, were much put upon the stretch. The
fibula was broken one inch above the lower
extremity of the malleolus externus which re-
mained in its place, still united by its ligaments

TXlfi ANCLE.

to the tarsus* The tibia was split clown for two
inches above the joint, leaving the greater part
of the articulating surface still resting upon the
astragalus, but the remaining portion of the
articulating surface with the shaft of the tibia
and the fibula passed through the wound at the
outer ancle. If therefore the bone had been again
returned to its situation, it could not have
remained there from the small portion of articu-
lating surface attached to it ; and if the project-
ing portion had been removed by the saw it
would not have adapted itself to the portion
of the tibia, which remained attached to the
astragalus.

The division of a targe bloodvessel might , with an r»i
extensive wound of the integuments , lead to a
necessity for amputation ,

but I should not at once proceed to the opera-
tion on that account. The case from Mr. Sancl-
ford, of Worcester, sent me by Mr. Carden,
clearly shews that the division of the anterior
tibial artery does not, if it be well secured, pre-
vent the patient's recovery* I also once saw a
compound fracture close to the ancle-joint, ac<*
companied by a division of that artery ; and al-
though the patient was in the hospital, and a
brewer’s servant, who possessed the worst con-
stitution to struggle against severe injuries, yet
this man recovered without amputation*

The posterior tibia! artery is a vessel of more
importance, and is accompanied by a large
nerve, which would not be likely to escape in-
jury when the artery was divided by the dislo-
cated bone* Yet the magnitude of the ante-
rior tibial artery and its free anastomosis with

172

Gangrene.

Contusion.

ON COMPOUND DISLOCATIONS Of

the posterior, would not entirely preclud ethe
hope of the foot being preserved under an injury
of the posterior tibial artery.

Mortification of the foot

Sometimes ensues, and becomes a sufficient rea-
son for amputating the limb; but this must be ge-
nerally done when limits appear to be set to the
extension of the mortification. However, it may
be observed, that in the mortification which en-
sues from the division of a bloodvessel I have
seen in the arm, where the brachial artery had
been divided and the elbow-joint dislocated, the
arm removed above the injured part, whilst the
limb was still dying towards the seat of the
wounded artery, and the patient did well. And
I have also known a case of popliteal aneurism in
which the artery and the surrounding parts were
so compressed by the swelling, that mortification
began at the foot and was extending to the
knee, and although no limit was yet set to the
mortification, the liinb was amputated, and the
patient did well. So that mortification, when
it arises from injury to a bloodvessel, admits of
a practice different to that which is pursued in
mortification arising from constitutional causes*

Excessive contusion may he another reason for

amputation ;

and therefore in those cases in which heavy
laden carriages pass over joints, and bruise
the integuments so as to lead to their forming
extensive sloughs, and produce at the same
time generally the worst examples of com-
pound dislocations, as regards the state of the

173

THE ANCLE,

bones, I should immediately amputate, for such
cases are very different to those which occur
from jumping from a considerable height, from
a carriage rapidly in motion, or from slipping
down in walking or running.

Extensive suppuration will also form a reason

for amputation.

I have known after an attempt to save the limb,
the patient have more extensive suppuration
than his constitution could support, followed by
an ulceration of the ligaments, by which the
joint became additionally exposed, and the
bones ultimately again displaced, leading to an
absolute necessity to remove the limb for the
preservation of his life,

A necessity for amputation may be also produced
by exfoliations of portions of bone ,

which, locked into the surrounding parts of the
bone, are incapable of becoming separated, and
thus keep up a state of continued irritation.
My friend, Mr. Hammick, has had the kind-
ness to send me a specimen of this kind,
which he was obliged to amputate. The loose
portion of bone was seated between the lower
extremity of the tibia and fibula, and reached
to the ancle-joint ; both the bones had been
broken, and had become reunited, and the
uniting medium had inclosed and incarcerated
the dead portion of bone. It is probable from
the appearance of the parts that this portion
of bone never would have been able to have
escaped from the place in which it was locked.

Suppura-

tion,

Exfoliation.

1 74

ON COMPOUND DISLOCATIONS OF

Deformity.

Excessive Deformity of the Fool

will also give rise to a necessity for this opera-
tion ; and this deformity will arise in three
directions. First, when the foot is suffered to
turn outwards at the time the leg is placed
upon the heel, in the dislocation inwards. Se-
condly, when it turned inwards in the disloca-
tion of the tibia outwards ; and, thirdly, the
foot being pointed. The first is best opposed
by placing the leg upon its outer side when
that is compatible with the treatment of the
wound ; in the second case, it is best to keep
the foot on the heel, with splints having foot
pieces both on the inner and outer side of the
foot; and the third requires similar splints,
and that a tape, as a stirrup, should be placed
under the foot, and fastened to the splint on the
fore and middle part of the leg to keep the foot
supported.

The following case from Mr. Norwood, of
Bath, shews the necessity for amputation, when
great deformity is permitted to occur.

CASE XIII.

I was sent for to Bradford, some years since,
to amputate a leg directly after an accident of
this kind. I found the lower extremity of the
tibia, with the astragalus loosely attached to it,
projecting at the inner ancle. The wound was
not large, and the soft parts were little injured.
I removed the astragalus, and reduced the tibia,
leaving it to rest upon the os calcis. I did not
again see him during the healing of the wound;
I believe it got well without any severe symp-
toms, but the os calcis became drawn up against
the posterior part of the tibia, to which it firmly

THE ANCLE,

united, and the foot became immoveable, with
the toe pointed downwards. In this state he
came to Bath two years afterwards ; I ampu-
tated the leg, and the patient did well.

GEORGE NORMAN.

Hath, August '2nd, 1819.

175

Amputation has been recommended in those cases

in which tetanus occurs after this injury .

Of tetanus, I have seen one case from com- Tetanus,
pound dislocation of the ancle, and have heard of
another. That which 1 saw was in a Mr. Yare, a
stable keeper, who had a compound dislocation
of the tibia inwards, and in whom I reduced the
bones, and placed the limb on its outer side.

For a few days he proceeded without any alarm-
ing symptoms. The only circumstance in which
lie differed from what I expected, was in the
slight inflammation which succeeded upon the
joint ; for the restorative process seemed to be
scarcely set up in him. When I paid him my
morning visit, several days after the accident, he
said, cc Sir, I believe I have caught cold, far
my neck is stiff f and as he said this, with
his lower jaw raised and his teeth closed, I
begged him to shew me his tongue, to as-
certain if his jaw were locked, and he tried
to open his mouth to protrude the tongue,
but he was unable to do so. I then desired
that Dr. Relpli might see him, who did all
his mind could suggest to arrest the progress of
the symptoms, but unsuccessfully, as the differ-
ent muscles of volition became affected in the
back, extremities and the abdomen, until he was
exhausted by irritation. To amputate under
such circumstances, would be most unjustifiable.

176

ON COMPOUND DISLOCATIONS OF

as far as the experience of* cases in this cli-
mate will enable me to form an opinion. I
have not seen amputation performed for com-
pound dislocation of the ancle, but I have for
compound fracture just above the joint ; and it
seemed to me to precipitate the fatal event. I
have also known, in one case, the finger ampu-
tated for tetanus arising from injury to it, but
still the patient died : and I have heard of a
third case in which it was also practised, but
still the issue was fatal. There is a species of
chronic tetanus which sometimes even succeeds
wounds, and which will occasionally get well,
and apparently, it recovers, even if but little
be done by medicine, and nothing by surgery.
And in such a case it would not be justifiable to
amputate, as the patient will get well without
it. If medicine does any thing in these cases,
submurias hydrargyri with opium, is that under
which I have seen the majority of cases recover.

A very Irritable stale of constitution

will sometimes render all treatment unavailing in
the attempts to save the limb, and will now and
then destroy , even if the operation of amputation
be performed. There are some persons originally
constituted with so irritable a system, that the
slightest injuries will destroy them. There are
a much greater number whose constitutions, ori-
ginally good, have been so much injured by
habits of excess, by want of exercise, by over
exertion of mind, by drinking freely of spirits,
and eating but little, that they are rendered in
the highest degree irritable.

Constitu-
tion irri-
table.

THE ANCLE.

177

CASE XIV.

One of the most curious examples of this kind
■which I have seen, was in a man who worked at
Barclay’s brewhouse, in the Borough. The cir-
cumstances were these : —

On Saturday he was turning a cask, and a
splinter of wood entered his thumb, which he
immediately drew out.

On Sunday night he requested his wife to rise
to make him a poultice, for his thumb, he said,
was painful.

On Monday he sent for Mr. John Kent, sur-
geon, in the Borough, who found his thumb
inflamed and painful.

On Tuesday the inflammation had extended
to the hand and fingers.

On Wednesday a swelling appeared at the
wrist, above the ligamentum annulare carpi, and
the man had a great deal of irritative fever, and
was obliged to keep his bed.

On Thursday, after lecture, Mr. Kent came
to me, requesting I would see this man, who had
been delirious during the night, his arm much
convulsed, and his body was becoming generally
so. I went with him, and, feeling the thumb,
discovered a fluctuation in the theca. I put
a lancet into the extremity of the thumb, and
a considerable quantity of pus issued. Gra-
tified with the expectation of his being relieved
by the discharge of the matter, I was going out
of the room to express this feeling to his friends,
when I heard a rustling at the bed behind me,
and upon Mr. Kent and myself turning back,

178

ON COMPOUND DISLOCATIONS OF

we saw him under the influence of a convulsive
fit, which raised him in part from his bed : he fell
back and expired.

Living as these persons generally do, princi-
pally upon porter and spirits, they have consti-
tutions which render them the worst subjects
for accidents.

The following case shews the violent symp-
toms and quick dissolution which will, from the
same cause, occasionally destroy in compound
dislocations of the ancle.

CASE XV.

.. .. . - . ■ '

On June the 10th, 1809, I was requested to

go immediately to Gracechurch Street, to see a
Mr. Fenner, who, in walking opposite to the
City of London Tavern, had slipped down from
the foot-way, and produced a compound disloca-
tion of the ancle. The tibia projected at the
inner ancle; the fibula was broken; the skin
was tucked in under the extremity of the tibia.

1st. I immediately procured a mattress for
him, instead of a feather-bed.

2nd. A many-tailed bandage ; splints lined
with wool ; pillows and tapes.

3rd. The skin was divided, and the bone
reduced ; but it was much opposed by violent
spasm of the muscles.

4th. The edges of the wound were closely ad-
justed.

5th. The bandage was applied, and splints ;
and the limb was placed upon pillows on its
outer side, with the knee bent.

THE ANCLE.

179

6th* Bled to 1 45, and opium given ; tinct.
opih gtt. xxx. '

June 11th. — He reported that his night had
been restless ; his tongue was white ; his pulse
beat 110 strokes in a minute; he had violent
pains in the ancle, and he had vomited. — Or-
dered oleum ricini, as his bowels had not been
relieved. Evening; he had almost constant
spasms of the muscles of the leg ; he has no
sleep, and has no appetite. The oleum ricini
had produced him four evacuations.

Jime 12th. — His pulse was 120; his tongue
more furred. He has violent and very frequent
spasms. He has nausea, but has not vomited
since the last report. He has had one evacua-
tion. Blood is extravasated about the ancle ;
a sanious serum is discharged from the wound.
Ordered opium.

June 13th. — Had slept three hours. There is
some inflammation about the wound and swell-
ing of the leg, with spasms, but they are less
violent. A poultice was applied to the ancle, and
fomentations ordered. Pulse 120; his tongue
was very much furred. Evening ; in most vio-
lent pain ; he was ordered submurias hydrargyri
five grains, with two grains of opium, and the
saline medicine with antimonv.

June 14th. — The spasms continue, but the
pain has in a great degree ceased. lie has had
several evacuations, but he has been delirious
during the night. The limb is but little swollen ;
the foot looks slightly inflamed, but there is no
healthy discharge or any granulations beginning
to form. The former treatment ordered to be
continued.

n 2

180

ON COMPOUND DISLOCATIONS OF

Corpulent

persons.

June 15th. — He passed a bad night, being
delirious through a great part of it. He had a
violent spasm in the limb this morning, by which
he produced a slight haemorrhage, which was
stopped by pressure. Leg swollen ; wound ap-
pears to be without action. His pulse is equally
quick, and he takes no nutriment.

June 16th. — He has spasms in the thigh of
the same side, and in the other leg, as much as
in the injured limb \ in other respects he re-
mains the same.

June 17th. — He was delirious during the last
night, and bleeding was again produced by the
violence of the spasms. — -His pulse was consi-
derably quicker than before.

June 18th. — He died at 4 o’clock in the after-
noon.

Persons ^bo are much loaded with adeps are
generally very irritable, and bear important ac-
cidents very ill ; indeed they generally die,
which ever plan of treatment be pursued: to
this, however, there are exceptions in those who
are corpulent, and who yet take a great deal of
exercise, as they will retain much vigour of con-
stitution ; and in such persons the limb may be
attempted to be saved, as in the case described
by Mr. Abbott, surgeon at Needham Market^
but in those who have become extremely fat,
and who have been addicted to habits of indo-
lence, there is little chance of preserving life but
by the operation of amputation.

I have thus endeavoured to explain what lias
fallen under my observation, or have been able
to learn from others upon this difficult subject ;
and 1 beg leave to express a hope, that any of

THE ANCLE.

181

my friends, who may have had cases under
their care, which would throw further light
upon the subject, will have the kindness to
communicate them to me, whether they make for
or against the advice I have given, as I have no
further wish but that all the points respecting
this severe accident may be fully elucidated and
established.

ON DISLOCATION OF THE TARSAL

BONES..

On the Dislocation of the Astragalus v

This bone is connected above and on the
sides to the tibia and fibula by its trochlea ; be-
low, it has articulatory surfaces for its junction Junctions
with the os calcis, to which it is united by bones°.ther
means of a capsular ligament; and anteriorly to
the os naviculare, by a capsular, broad, and in-
ternal lateral ligament. A simple dislocation of
the astragalus sometimes, but rarely, occurs ;
and a compound luxation is still more rare.

A simple luxation is a most serious accident, simple .

1 . dislocation,

being very difficult to reduce ; and should the re-
duction not be effected, the patient is ever after
doomed to a considerable degree of lameness.

I was sent for into the country to visit a pa- case,
tient, and the surgeon who I met there request-
ed me to see a person who had a dislocation of
the foot, which had happened several weeks, but
it had not proceeded to his satisfaction. Upon

182

ON DISLOCATIONS OF

Compound

dislocations.

examination I found the astragalus dislocated
outwards, and the tibia broken obliquely at the
inner malleolus. Every attempt to reduce it
was made, which the surgeon, who is an ex-
tremely well informed man, could adopt ; five
persons kept up a continued extension where
the accident first happened, but without effect ;
the patient was then taken home, and several
persons were employed in extending the foot,
and it was thought, after a time, with some suc-
cess, but the reduction could not, by all their
efforts, be rendered complete ; for the astragalus
still remained projecting upon the upper and
outer part of the foot. The extension could
not be carried further, for the integuments
sloughed from that already made, and the wound
was a long time in healing. The limb deviates
much from its natural shape ; the toes are turn-
ed inwards and pointed downwards; there is
some little motion at the ancle, and a slight de-
gree of it between the projecting and raised as-
tragalus and the other bones of the tarsus. This
accident, then, is of a most serious nature ; for
this gentleman had placed himself under the
care of a most intelligent and persevering sur-
geon, and yet the attempts which he made at
reduction were not entirely successful, merely
from the nature of the accident, and not from
any fault in the means which were pursued.

Of the compound dislocations of this bone, I
have only seen one instance ; and in that case
the operation of amputation was performed. It
will be seen, however, in the preceding pages,
that Mr. Trye removed the bone in this acci*
dent, and the case did well*

THE TARSAL BONKS*

183

The five anterior bones of the tarsus are some-
times dislocated from the os calcis and the as-
tragalus. There is a transverse joint between
these bones, formed by the astragalus and os
calcis posteriorly, and by the os naviculare and
os cuboides upon the fore part, which support
the three ossa cuneiformia. This joint is some-
times, but rarely dislocated by very heavy
weights falling upon the foot, of which the fol-
lowing is an example.

A man working at the Southwark Bridge had
the misfortune to have a stone of great weight
glide gradually upon his foot. He was almost
immediately brought to Guy’s Hospital, and the
appearance of the foot was, that the os calcis
and astragalus remained in their natural situa-
tions, but the fore part of the foot was turned
inwards upon those bones. When examined by
the young gentlemen, the appearance was so
precisely like that of a dub foot , that they could
not at first believe but it was a natural de-
fect of that kind ; but upon the assurances of
the man, that his foot, previously to the acci-
dent, was not distorted, an extension was made
by fixing the leg and the heel ; the fore part of
the foot was then drawn outwards, and thus
the dislocation was reduced. This person was
discharged from the hospital in five weeks quite
recovered, having the complete use of his foot.

The following interesting cases were under
the care of Mr. Henry Cline ; and for the par-
ticulars I am indebted to his apprentice, Mr*
South.

184

ON DISLOCATIONS OF

CASE I.

Thomas Gilmore, set. 45 years, an Irish la-
bourer, was admitted, under Mr. H. Cline, into
St. Thomas’s Hospital, about eleven o’clock of
the morning of

March 28, 1815. Whilst walking at the New
Custom blouse this morning, he received a blow
on the heel, from the falling of a stone, (said
to be half a ton weight) which made a wound
on the fore part of the ancle-joint, and dislo-
cated the foot at the astragalus.

The parts were in the following state : — a
wound extended from opposite the middle of
the base of the tibia, round the upper part of
the instep, to the external malleolus, which
exposed the articulating surface of the astra-
galus with the navicular bone on the fore part,
as well as that for the os calcis, on the outside,
from both of which bones it was displaced ; its
connection with the tibia and fibula, however,
was undisturbed ; the tuberosity of the os calcis
projected outwards, but the rest of the foot
turned in, so that the toes pointed much in-
wards towards the opposite foot.

The reduction was effected by extending the
foot, and rotating it outwards ; the wound was
brought together with straps of adhesive plais-
ter ; the leg was covered with soap plaister and
put in a fracture-box, on the heel ; the parts
were kept uncovered, and a slight haemorrhage
supervening, linen rags dipped in cold water
were applied,

THE TARSAL BONES.

185

He is a robust man, has been in the habit of
drinking, and says he has been subject to the
gout.

March 29. Had not slept much, as on falling
asleep, spasm was produced ; pulse about 80 ;
skin cool ; he has taken the sulphate of mag-
nesia, which has produced two evacuations ;
the part is not tumefied but has been painful.

March 30. Has passed a very restless night,
having been delirious ; pulse 120; skin hot and
dry ; fauces parched ; does not now seem quite
clear in intellect ; in the morning he has had
more than one rigor ; a dose of sulphate of
magnesia, with infusion of senna, had procured
three loose, but healthy stools ; the part has be-
come more swollen and painful ; ordered , fever
mixture, with ten drops of antimonial wine,
every six hours ; in the afternoon he had three
more stools.

March 31. Is still delirious, and did not sleep
last night; skin very hot and dry; mouth parched;
pulse about 112 ; has had two stools this morn-
ing, without medicine ; the rigors still continue
occasionally, and he is also affected with tremors;
the inflammation is extending up the leg, and
a bruise, which he received on the same leg, is
now ulcerating ; to it, wax and oil dressing is
applied.

April 1, 1815. Has been less delirious than
on the two former nights ; pulse 122 ; tongue
cleaner ; no stools.

April 2. Has slept better than he has yet
done ; is not at all delirious ; pulse 96 and soft ;
skin moist, and he has perspired freely ; no

186

ON DISLOCATIONS OF

stools ; urine in large quantity, but said to be
high-coloured ; the tremors have a good deal
left him, and he feels altogether comfortable,
except that there is a good deal of pain in
the injured part, which he ascribes to a rheu-
matic affection, to which he has been subject;
there is a slight erysipelatous inflammation of
the leg, with some oedema.

April 3. Has passed a tolerably good night ;
is sensible ; pulse 100 ; bowels costive ; the
ancle easy.

April 4. Pulse 96 ; skin moist ; has had two
stools ; the erysipelatous inflammation has ex-
tended rather above the internal condvle of the

os femoris, and small yellow vesicles have
formed ; this seems to have proceeded from
the bruise on the calf of the leg, which has
now gone into a state of superficial ulceration ;
soap cerate was applied to this wound, and the
spirit lotion on the limb as far as the inflam-
mation extended ; the wound on the ancle was.
dressed, for the first time, to-day, the liga-
ments appear to be sloughing ; the strapping
was left off*, and wax and oil dressing applied.

In the afternoon, his pulse 104, seems restless
and says his head feels rather light ; had ano-
ther stool towards evening.

April 5. Has been delirious all night; skin hot
and dry ; pulse 108, and weak ; these symptoms
indicating fever, of a different kind to the pre-
ceding, viz. secondary and sympathetic with
the erysipelas ; the wound at the ancle is gra-
nulating, and secreting healthy pus ; that on
the leg is very painful, and has taken on a

THE TARSAL BONES.

187

sloughy appearance: ordered decoction of bark
every four hours, with opium, if diarrhoea is
produced.

April 6. Was delirious ; pulse 100 and weak;
skin perspirable ; has had two stools ; the in-
flammation extends nearly to the groin, and
at one part of the thigh, where the cradle
has accidentally pressed the skin, seems as if it
would slough ; takes a grain of opium twice
a day.

April 7. Slept pretty well ; wanders ; pulse
110, but strong ; skin not very hot; no stool ;
much pus is discharged from the wound at the
ancle.

April 8. Has been restless during the night ;
pulse 96, with some power ; skin moderately
hot ; is thirsty ; delirious ; tongue rather foul ;
bowels costive ; his urine, of which he still
voids a great quantity, scalds him ; pus is
forming in different parts of the limb, and
the inflammation on the thigh seems now to be
stationary.

April 10. Slept well ; is not delirious ; pulse
96, not weak ; skin not very hot ; has appetite;
the part is painful, but the inflammation on the
thigh is considerably diminished, and the sloughs
are circumscribed ; pus healthy ; a few days
since, he was ordered a pint of porter daily,
which is now increased to two pints.

April 11. Says he occasionally wanders;
pulse 100, rather weak ; appetite tolerably
good ; skin moist ; has had stools.

April 12. The inflammation is less; the
opium which he takes gives him good nights ;

188

ON DISLOCATIONS OF

the wound at the ancle is much the same ; the
sloughy sore on the calf of the leg, better ;
to-day he was moved into a clean bed, and the

limb placed on the outer side, as he wishes to
lay on his side.

April 13. Is composed ; pulse 98 ; skin
cool ; feels weak ; has not much appetite, but
likes his porter ; the sloughs on the leg sepa-
rate slowly.

April 14. The limb returned to its old posi-
tion on the heel, as he was not so comfortable
when it was placed on the side.

April 17. Pulse 92, and weak; has little or
no appetite ; the bark and opium were left off
to-day, as they seem to affect his head ; a poul-
tice was applied to the wound on the calf of
the leg, and strapping on that at the ancle ; it
being hoped, that by the support which it might
afford, it would diminish the discharge.

April 22, As his appetite does not get better,
and he gets no sleep, the bark and opium were
resumed, and an additional pint of porter given,
so that he now takes three pints a day ; his
pulse is not so weak ; spirits good ; at times he
is in great pain ; strapping is applied to all the
wounds ; the sloughs nor separated.

April 28. Continues much the same ; one
. slough on the leg has separated ; that at the
ancle not yet ; the part is tolerably easy ; the
discharge not great.

May 15, 1815. All the sloughs have sepa-
rated, and the wounds are gradually healing up,
but he is very weak and his appetite is bad.

May 20. Oil was ordered to be rubbed on

THE TARSAL BONES.

189

such parts of the leg as would bear it, and
then washed off, as it was thought this would
promote circulation in the limb, which was
cedematous ; however it was soon left off, as it
occasioned inflammation. About this time his
medicines were omitted.

May 29. An abscess, which had formed on
the calf of the leg, was opened.

July 14, 1815. All the dressings are left off
to-day ; he is perfectly capable of lifting up his
leg, and has slight flexion and extension of the
foot.

After this time he rapidly improved ; and
having left his bed, in a short time was walking
about the square on crutches.

Sept . 21, 1815. He went out, being able to
walk tolerably with a stick.

CASE II.

Martin Bentley, get. SO years, a sailor, was
admitted under Mr. H. Cline, into St. Thomas's
Hospital, at twelve o’clock at noon of

June 21, 1815. He had been overpowered
this morning by some stones which he was en-
deavouring to sling in a ship’s hold, which
knocked him down and fell on him, causing a
compound fracture of the tibia and fibula of the
left leg, near the middle, with dislocation of
the astragalus of the other foot from the other
bones of the tarsus.

As there was much laceration of the skin
and muscles, Mr. H. Cline thought right to
amputate the limb below the knee, which was
done about three hours after his admission. He

190

ON DISLOCATIONS OF

complained of much pain during the operation*
with frequent jerking of the limb; the muscles
were extremely rigid ; five ligatures were ap-
plied, and the wound dressed as usual.

The other foot presented the following ap-
pearance t the protuberance of the os calcis
had nearly disappeared, but the os calcis late-
rally and on the outer side projected much be-
yond the outer malleolus, just under which
however was a remarkable depression ; just be-
low the inner malleolus was a remarkable and
unnatural projection ; the whole foot seemed
somewhat displaced outwards, the toes turning
out ; the astragalus must here have been dislo-
cated from both the navicular bone and os
calcis, and thrown inwards, so as to have its
tinder articulatory surfaces for the os calcis
resting on the inner edge of that bone.

After the amputation the dislocation was re-
duced by fixing the knee, having the thigh
bent at right angles with the body, then laying
hold of the metatarsus and protuberance of the
os calcis, and drawing the foot gently and di-
rectly from the leg. During this extension
Mr. H. Cline put his knee against the outside
of the joint, and the foot being pressed against
it the os calcis and navicular bones slipped into
their place, carrying with them the rest of the
foot, and the deformity disappeared. He was
then carried to bed, and an outside splint, being
well padded, was applied, and secured by tapes,
and the leg, as far as could be, placed on the
outer side. Goulard’s wash was applied.

June 24. The lead wash to be left off, and
soap cerate put on the right leg.

THE TARSAL BONES.

191

June 25. The cerate has blistered his leg in
several places, and he complains of more pain
than yesterday, at his ancle.

June 28. The stump, which is going on well,
dressed to-day ; one ligature came away ; the
pain in his ancle has subsided.

July 1, 1815. Complains of uneasiness about
the epigastrium, and sickness; pulse 112 and
hard ; jviij. blood taken from the arm.

July 2. All untoward symptoms have disap^
peared.

July 4. Two ligatures came away ; a sore,
which is the effect of the soap cerate, on the
inner malleolus, is dressed with wax and oil.
He is now capable of raising his leg, which
however is numb.

July 13. Tjie ligatures not seeming disposed
to come away, a piece of whalebone was ffxed
on the side of the stump to which they were at-
tached, and so kept constantly tight ; was put
on the house diet to-day ; has previously been
on the milk.

July 19. One of the ligatures removed, with
some difficulty, by Mr. H. Cline ; the other
came away easily on the following day.

Aug . 7, 1815. Walked in the square, the first
time since the accident.

Aug . 26. Went out ; capable of walking to-
lerably well.

I conversed with Mr. Henry Cline on the sub-
ject of these accidents, and Mr. Green, who saw
the preceding cases in the commencement, has
sent me the following letter respecting them.

192

ON DISLOCATIONS OP

Lincoln7 s Inn Fields, Ang. 19, 1819t

MY DEAR SIR,

In the notes of Martin Bentley’s case, which
I made at the time he was under Mr. Henry
Cline’s care, in St. Thomas’s Hospital, I find
it stated that the right astragalus was dislocated
inwards, i. e . that the os calcis, with the rest of
the foot, was thrown outwards ; and the descrip-
tion which I have there given of the appear-
ances, is — that the whole foot seemed to be
somewhat displaced outwards ; that the os calcis
projected laterally much beyond the outer mal-
leolus, whilst the protuberance of that bone
had nearly disappeared ; and that in conse-
quence of the astragalus retaining its situation,
there was a remarkable depression beneath the
outer malleolus, between it and the displaced
os calcis ; and as remarkable a projection pro-
duced by the astragalus, below the inner mal-
leolus. This accident, which was accompanied
with a compound fracture of the opposite leg,
had been produced by the fall of several large
stones. The reduction of the dislocation was
effected without difficulty, first, by fixing the
knee, then by making extension of the foot
gently and directly from the leg, by laying hold
of the heel with one hand and placing the other
on the dorsum of the foot; and lastly, by press-
ing the foot inwards, whilst a counter-pressure
was made with the knee upon the lower extre-
mity of the tibia on the opposite side. The
foot was afterwards placed on its outside, and se-
cured upon a well padded splint.

In the case of compound luxation of the tar-

THE TARSAL BONES*

193

sal bones, likewise under the care of Mr. Henry
Cline, it appears, according to my notes, that
the astragalus was displaced outwards, i. e. that
the other tarsal bones were thrown inwards. I
find that the appearances are described to have
been — that the foot was turned considerably in-
wards ; that the Articular surface on the head of
the astragalus, which is received into the cup
of the navicular bone, was exposed through an
extensive but tolerably clean cut through the
integuments, and that the articulating surface
of the os calcis for the astragalus might also be
perceived on the outer side. The accident was
said to have been occasioned by the fall of a
heavy stone, which had struck his heel. Re-
duction of the dislocated parts was accom-
plished, first, by bending the leg so as to relax
the muscles, and then by extending the foot in
the manner described in the former case, and
by rotating it at the same time outwards.

The patient was a robust, but not corpulent,
labouring man, between forty and fifty years of
age. He stated that he had been in the habit
of drinking, and that he was occasionally sub-
ject to gout.

You have already, I believe, been made ac-
quainted with the particulars of the progress of
the case, of which the most remarkable features
appeared to be, that the primary constitutional
irritation was violent, but of short duration,
and that his recovery was retarded by exten-
sive erysipelatous inflammation which termi-
nated in sloughing, and by the formation of
matter at the part, accompanied by irritative

194

ON DISLOCATIONS OF

fever and loss of strength ; but that his reco-
very, although tedious, was complete.

I remain, my dear Sir,

Your obliged and obedient Servant,

JOSEPH HENRY GREEN®

Of the Dislocation of the Os Cuneiform e Internum .

I have twice seen this bone dislocated, once
in a gentleman who called upon me some weeks
after the accident, and the other case occurred
in Guy’s Hospital very lately. In both these
cases the same appearances presented them-
selves. There was a great projection of the bone
inwards, and some degree of elevation, from its
being drawn up by the action of the tibialis anti-
cus muscle, and no longer remaining in a direct
line with the metatarsal bone of the great toe.
In neither case was the bone reduced, but the
former patient walked with but little halting,
and I believe would in time recover the use of
the foot, so as not to appear lame. The cause
of the accident was in this gentleman, a fall
from a considerable height, by which the liga-
ment was ruptured which connects this bone
with the os cuneiforme medium, and with the os
naviculare.

The case in Guy’s Hospital my apprentice,
Mr. Babington, informs me, happened by the
fall of a horse, and the foot was caught between
the horse and the curb stone.

The treatment of this accident will consist,

THE TARSAL BONES*

195

in confining the bone in its place, by at first bind-
ing it with a roller dipped in spirits of wine and
water, with which it must be constantly kept
wet. When the inflammation is subdued, a
leather strap is to be buckled around the foot,
to keep the bone in its place till the ligament be
united with the bone in its natural position.

The metatarsal bones I have never known
luxated. Their union with each other, and irre-
gular connection with the tarsus prevent it ;
and if it ever happens it must be a very rare
occurrence.

The toes are sometimes dislocated ; but X
will reserve that subject until the dislocations
of the fingers are described.

o 2

ESSAY II.

incised
wounds
rarely heah

UNNATURAL APERTURES

IN THE

URETHRA.

By Mb. ASTLEY COOPER.

That openings made into the urethra by
cutting instruments are healed without diffi-
culty, is evinced by the operation for the
stone in the bladder, in which this canal is ex-
tensively opened ; and in the removal by in-
cision of a calculus lodged in any part of the
urethra. But when apertures are formed in
this part, either from diseased states of the
constitution and of the urethra, or from disease
in the canal only, and when they are accom-
panied by any considerable loss of substance
in the urethra and corpus spongiosum, they
are generally very difficult of cure.

It most frequently happens that fistulous
orifices from this canal are the result of stric-
tures in the urethra. The impediment which
this disease produces to the passage of the

ON UNNATURAL APERTURES IN THE URETHRA. 19Y

urine enlarges the lacunae situated behind the Cause,
stricture, and the frequent pressure of the urine
upon them and upon the sides of the urethra leads
to an ulcerative process, by which the urine be-
comes applied to a new surface ; it irritates the
part, occasions the formation of an abscess, into
which the urine gains access ; and when the
matter is discharged, be it by nature or by art,
the urine passes through the aperture, and con-
tinues generally to do so whilst the stricture
remains. As the seat of the greater number
of strictures in the urethra is beyond the mid-
dle of the canal towards the bladder, the aper-
tures are most frequently seated in the peri-
neum ; but they are in different persons from
an inch within the urethra to its extremity at
the bladder.

As soon as these abscesses, which are the
forerunners of the fistulas, can be distinctly dis-
covered to contain matter, it is the best prac- Treatment,
tice to pass a lancet into them, to discharge
the matter. It is advantageous in preventing
extensive destruction of the parts by ulceration,
and they not unfrequently immediately heal
even so as to prevent the fistulous orifice, and
it becomes the means of lessening the tendency
those dangerous extravasations of urine into the
scrotum, which if they are not early opened
often prove destructive to life.

The mode of treatment of such apertures is
easily understood in principle, and their cure
in most situations is readily effected in practice.

It consists in principle in removing the impedi-
ment to the passage of the urine, by enlarging
the urethra at the strictured part, and thus

198

ON UNNATURAL APERTURES

Catheter*

Size.

Caustic.

prevents the urine from making unnatural pres-
sure against the side of the canal, and in practice
it depends on the introduction of metallic bou-
gies, increasing their size gradually until it reaches
somewhat beyond that of the natural diameter
of the passage, and thus the urethra becomes
stretched in a degree to admit readily the pas-
sage of the urine through what was previously
a contracted canal*

In other cases it is sometimes required,
to introduce a pewter catheter of large size
into the bladder, to suffer it there to remain
to draw the urine through it, and thus pro-
ducing the double effect of extending the
stricture and preventing the passage of the
urine through the opening, it often becomes
the means of permanent relief.

The size of the instruments employed for
these purposes must be varied according to cir-
cumstances, for there is in different persons a
great diversity in the natural diameter of the
canal, and at different ages, even after man-
hood, the urethra varies exceedingly in the di-
latability of its canal.

Caustic, which was formerly much employed,
is now comparatively seldom used for this pur-
pose ; yet cases do occur in which, from long
neglect, the urethra and the parts surrounding
the stricture become so exceedingly altered in
their structure that no instrument can be passed
through the part without a degree of violence
which will be dangerous to life, and in which
the slower influence of the caustic will be at-
tended with less danger than the use of the
metallic bougie. But it is principally in the

IN THE URETHRA®

199

class of patients who are admitted into our hos-
pitals, in whom such extensive mischief has
arisen from long neglect, as to require the appli-
cation of the caustic.

But there are apertures of this description tenure
so situated and connected with other parts as to from the
preclude the possibility of healing them by the part of
usual means of treatment, and in which other toethuerethrd
measures are consequently obliged to be em- rectum-
ployed.

CASE.

A gentleman came to London under the fol-
lowing circumstances. He had an abscess form-
ed upon the anterior and lateral part of the
rectum, which had discharged itself after long
continued suffering into the rectum, just above
the verge of the anus. The surgeon, whom he
consulted in London, discovering the aperture,
divided the sinus, and he returned into the
country ; but the wound did not heal, and a
considerable discharge proceeded from it. Ob-
serving the discharge with attention, he found
that after making water the urine passed
through the aperture, and that consequently
there was some communication between the
urethra and rectum. Alarmed at this circum-
stance he came to London, and placed himself
under my care. I examined his urethra, and
finding some obstruction at the apex of the
prostrate gland, advised him to make use of
large metallic bougies until the natural diame-
ter of the urethra at that part had been re-es-
tablished, hoping that in this way the opening

200

ON UNNATURAL APERTURES

would be disposedtohealastheurinefound a more
ready course than through its natural channel.
He persevered in the use of these instruments
for several weeks, but with no apparent advan-
tage, as the urine still passed by the fistulous
aperture. I therefore advised the introduction
of a metallic catheter of large size into the
urethra, and to give it full effect, recommended
that he should steadily observe the recumbent
posture, which he did for a month, during
which period the urine did not pass by the rec-
tum ; but as soon as the instrument was with-
drawn the urine resumed its former unnatural
course. He returned into the country greatly
disappointed, and after remaining there for some
time, and finding his complaint increasing, he
again applied to me, and I advised him to un-
dergo the following operation for his relief I
introduced a catheter into his bladder, and my
finger into the rectum, and then made an in-
cision, as in the operation for the stone, in the
left side of the rhapha, until I felt the staff
through the bulb. X then directed a double-
edged knife across the perineum, between the
prostrate gland and rectum, intending thus to
divide the fistulous communication between the
urethra and the bowels. A piece of lint was
introduced into the wound, and a poultice was
applied over it. When the lint was removed
the urine was found to take its course through
the opening in perineo ; the aperture in the
rectum gradually healed, and that of the peri-
neum quickly closed, after which the urine
took entirely its natural course. Whilst the
Wound which X had made was healing, one of

IN THE URETHRA.

201

the testicles became enlarged and inflamed, as
I supposed from the irritation on the extremity
of the vas deferens, or in sympathy with an irri-
tated vesicula seminalis on that side. This in-
flammation left some hardness of the epidydi-
mis, but no further inconvenience, and the
urine has never since deviated from its natural
channel.

Apertures are sometimes formed in the ure-
thra from a process of ulceration beginning in ulceration,
a bad constitution, without their being accom-
panied with stricture.

A person whose constitution is broken by
excess, or who is naturally feeble, will have a
slight discharge take place from his urethra
without any previous sign of disease, or without
the possibility of a well founded suspicion of
gonorrheal infection ; a swelling forms in a line
with some part of the urethra, which proceeds
to suppuration \ a poultice is applied, and the
abscess breaks, or it is opened by art, and the
urine takes its course through the wound, whilst
a considerable discharge still continues from
the urethra. These circumstances arise either
from ulceration in the mucous membrane of the
urethra, or from abscesses in the lacunas ; and I
believe more frequently from the latter than
the former. It is the usual practice in these
cases to begin directly with the use of bougies,
but it is not judicious to do so, as they only No bougies
add to the tendency to ulcerate, and increase employcd*
both the local and constitutional irritation.

A nobleman came to London with one of
these abscesses, and with a copious discharge
from the urethra. His constitution was previ-

202

ON UNNATURAL APERTURES

ously much enfeebled, and it suffered extremely
from the local irritation. A bougie was once
passed into his bladder, but no stricture was
found. He* had great fear of bougies, and re-
quested that no more might be introduced.
The abscess was poulticed, and the matter dis-
charged by the perineum, but still it continued
to pass both by the urethra and by the aperture
in perineo. The poultice was continued, and
his constitution was endeavoured to be im-
proved by attention to his diet, by alterative
and by tonic medicines. He soon amended in
his general health ; the discharge from the pe-
rineum gradually lessened, and that from the
urethra entirely ceased. He recovered, and has
remained well with respect to this disease for
several years. Contrast this with the following
example. A gentleman had a slight discharge
begin from his urethra. He was a married
man, of excellent moral character, who had
never exposed himself to the possibility of
any infection. The discharge from his ure-
thra at first appeared gleety, but it afterwards
became purulent, without any pain or diffi-
culty in passing the urine. Notwithstand-
ing this a bougie was employed, under the
use of which the irritation increased, the dis-
charge became greater, and his general health
suffered. A swelling then formed under the
urethra, within the scrotum, and which after
great local and constitutional irritation dis-
charged itself, and the urine passed through the
aperture in the scrotum. The bougie was again
employed, to extend the urethra and to heal
the opening from it into the scrotum ; but in a

IN THE URETHRA.

203

short time another abscess formed in perifteo,
and from this the urine became extravasated
into the perineum and scrotum, and a free open-
ing was obliged to be made for its discharge ;
but extensive sloughs followed ; his constitution
became extremely irritated and reduced, and he
died of this complaint. Upon opening him,
two ulcers were found in the urethra, without
any appearance of stricture.

If this disease had been from the first consti-
tutionally treated, instead of being irritated by
the injudicious employment of bougies, this per-
son would probably have had his life preserved.

Apertures connected with loss of substance
in the urethra are extremely difficult to heal.
They are usually seated in that part of the
urethra which is placed before the scrotum.
They generally pass longitudinally, and reach
to the extent of from half an inch to an inch ;
sometimes one-third of the urethra is removed ;
at others, half the canal, and with the membrane
of the urethra, the lower part of the corpus
spongiosum which adhered to it. A part of the
urine passes by this unnatural opening, and some-
times the whole of the urine and semen, when
the opening is large. The patient’s mind suffers
extremelv from the defect, as he considers him-
self emasculated ; and the greatest inconvenience
arises from the direction which the stream of
urine takes in its discharge. The cause of the
aperture is an abscess in one of the lacunae, at-
tended with a disposition to the sloughing process;
and when the matter is discharged, the slough
which follows removes the lower portion of the

Loss of
substance
in the
urethra.

ON UNNATURAL APERTURES

urethra opposite to the lacuna, and thus pr cp
duces a large aperture.

These cases are, I know, considered by some
of my professional brethren as incapable of cure,
and patients labouring under them have been
abandoned to despair; but the following ex-
amples may, perhaps, lead to attempts at relief
which have not hitherto been made ; and it is
the favourable result of these which has induced
me to venture to give this short essay upon this
subject.

CASE I.

A gentleman who had lately returned from
India had a chancre at the orifice of the urethra,
accompanied by a high degree of inflammation
of the glans, prepuce, and skin of the penis, to
the pubes and scrotum. The urethra sloughed
at the junction of the scrotum with the penis,
leaving an opening by which the urine was
freely discharged. This opening became healed
at its margin, but a large fistulous orifice still
remained in the urethra shewing not the small-
est disposition to heal, and exposing the patient
to great inconvenience in the discharge of the
urine.

The first surgeon whom he consulted advised
him to introduce bougies three or four times in
the day ; which he persevered in doing, without
effect. The next attempt which was made to
heal it was by the application of blisters, proba-
bly in the hope that excoriating the edge might
give a disposition to granulation, and thus lead

IN THE URETHRA*

205

to the closure of the aperture. This plan was,
however, entirely un successful*

The next trial consisted in paring the edges
of the wound, introducing pins, and bringing
the edges of the wound together by the twisted
suture ; but this also proved abortive.

At this time he applied to me } and conceiv-
ing that a simple suture might answer the pur-
pose better than the pins, I pared the edges of
the sinus and sewed it together by two threads ;
I then passed a catheter into the bladder, to dis-
charge the urine without inflaming the cut sur-
faces. On the third day, however, I found that
the urine had passed by the side of the catheter,
destroying the adhesive process ; and when the
ligatures separated on the fifth day, no union had
been produced. Feeling it would be quite use-
less to repeat these trials, and seeing that the
scrotum formed two thirds of the opening, and
the skin of the penis the other one third, I
thought that it might be possible to heal it upon
the principle of the contraction of the skin in
cicatrization. In June, 1818, I applied the
nitrous acid upon the edge of the fistulous ori-
fice and upon the skin, to the extent of three
quarters of an inch around it ; the skin sloughed
superficially, formed granulations, and healed.
It soon afterwards began to contract, so as to
shew that the principle would ultimately much
diminish the orifice. In the month of October
succeeding, I again applied the acid, and with in-
creased effect ; at the end of November the
application was repeated by himself, and the
opening, from the size of a pea, was reduced to
that of a pin. On January the 22nd, 1819, it was

206

ON UNNATURAL APERTURES

New

urethra.

again touched, but very lightly. In March the
caustic was last applied, and in a fortnight the
orifice was closed, and not the smallest quantity
of urine has since passed. The mental suffer-
ings produced in the patient by this orifice, can-
not be described ; and the happiness he felt in
his recovery was unbounded.

But still it is only in cases in which the skin
is very loose, or the scrotum is forming a part of
the fistulous orifice, that this plan would suc-
ceed ; as, when the skin is tight, it would be
scarcely possible to draw it together so as to
produce its union. Some other plan must be
therefore resorted to when this is the state of
the parts ; and I thought that an operation might
succeed similar in principle to that which has
been performed for time immemorial, in India,
of making a new nose, and which has been
successfully performed by my friends, Mr. Car-
pue and Mr. Hutchinson, in London, as well
as the operation of making a new under-lip
from the skin beneath the chin, which was
performed by my friend Mr. Lynn, surgeon
of the Westminster Hospital, and is so highly
creditable to him ; by which, not only a new
lip was produced, but even the beard grow-
ing upon that lip. I conceived that a piece
of skin might be raised from the scrotum ; that
the edges of the fistulous orifice might be pared,
and the skin removed to a small extent around
it, and that the skin thus raised from the scro-
tum might be turned half round, so as to apply
its raw surface to the opening, and upon the
edges where I was in hopes it would unite. The
case which led me to contemplate this operation,

IN THE URETHRA.

207

I attended first with Mr. Tipple, surgeon at
Mitcham ; and when the patient removed to
London with Mr. Hunter of Tower Street,
and his son, a very excellently well-informed
surgeon and amiable man, who has had the
kindness to furnish me with the following par-
ticulars of a case, the result of which has afford-
ed me a great deal of satisfaction ; and as the
operation is so simple that it may be performed
even by those who are not frequently in the
habit of operating, and is likely generally to suc-
ceed, I hope it will be useful to many who have
been deemed incurable.

CASE II.

Of Abscess in the Urethra .

In the beginning of July, 1818, Mr. H— t,
aet. 56, had a violent attack of inflammation in
the penis and scrotum, attended with enormous
swelling, the consequence of neglected stricture;
this was treated in the usual manner, by purga-
tive medicines, fomentations, and poultices.

July 9th. — A large abscess was opened oppo-
site the bulb of the urethra, which discharged a
great quantity of very foetid matter.

July 30th.— Mr. Astley Cooper found it neces-
sary to introduce a silver catheter, which was ef-
fected with great difficulty, on account of the re-
sistance of two firm strictures, and the highly
inflamed state of parts ; this was worn for three
weeks, during which time another abscess opened

Aperture
closed b}>’
a portion of
skin.

208

ON ABSCESS

at the under part of the urethra, immediately an**
teriorly to the scrotum ; the swelling and inflam-
mation gradually abated, and the fistulous orifice
behind the scrotum closed ; but that at the fore-
part continued to enlarge till it measured half
an inch in length, and was of sufficient width to
admit with ease the largest catheter ; in this
state it continued nearly four months without
any sensible diminution in size ; the edges were
quite callous, and never shewed the least dispo-
sition to granulate, notwithstanding the repeated
application of the nitrate of silver and other sti-
muli* Attempts were also made to produce
union by adhesion, but from the great loss of
substance it was impossible to keep the edges in
contact* The urine passed almost wholly by
this aperture, unless drawn off by a catheter.
As there appeared no means of relief from this
distressing condition, except by surgical opera-
tion, and from the extent of the wound, bringing
the edges together either in the transverse or
longitudinal direction, offered very little chance
of success, Mr. Cooper proposed to supply the
deficiency by a covering of integument from the
scrotum. With this view the following opera-
tion was performed.

December 9th. — An elastic catheter being
passed into the bladder, the callous edges of the
opening were pared off, so as to produce an en-
tire new surface ; a portion of integument was
then dissected from the scrotum (leaving it at-
tached at the upper part) and turned over upon
the wound, to which it was exactly fitted ; this
was held down by four sutures covered by small
strips of adhesive plaister \ a bandage was ap-

IN THE URETHRA.

plied to support the scrotum, and the patient
placed on his back in bed.

December 10th. — -Much aching pain in the
part ; a slight oozing of matter by the side of
the instrument at the extremity of the penis.
An enema was exhibited to prevent straining
during the evacuation of the bowels ; a little
urine was, however, forced through the wound.

December 11th to 14th. — The discharge of
matter through the natural orifice of the urethra
increased ; scrotum swoln and inflamed ; a small
quantity of urine again escaped by the wound
on the 12th and 13th; the bowels were kept
soluble by the daily administration of clysters
and mild aperient medicines. Saline medicines
produced considerable inconvenience by their
diuretic operation.

December 15th. — The dressings were entirely
removed ; the edges of the flap appeared in
perfect apposition with the parts beneath, but
the skin was thick and oedematous, particularly
at the upper part ; the sutures all retained their
hold ; the scrotum was much excoriated and in-
flamed by the acrid discharge ; the wound was
carefully cleaned ; two straps of adhesive plaister
were applied, over these a piece of lint spread
with simple cerate, and the bandage to support
the scrotum. After this the dressings were re-
newed every day in the same manner.

December 18th. — A little urine again escaped
by the wound.

December 19th. — The catheter which had re-
mained in the bladder ever since the operation,
became this evening completely stopped up ; it
was therefore withdrawn, and another intro*

209

210

ON ABSCESS

duced ; the slight pressure upon the wound, in
passing it, did not appear in the least to disturb
the union, though it was followed by a great
deal of pain at the end of the penis.

December 20th.— Much acrid discharge from
the wound, (principally from a small opening
on the right side) ; considerable excoriation of
the cuticle.

December 21st.— The upper and left side of
the flap appears perfectly united ; the urine,
which had hitherto been loaded with a thick
mucus, and very offensive to the smell, assumed
a more healthy appearance, and soon became
perfectly natural.

December 22nd.— The two upper sutures ul-
cerated through the skin.

December 23rd.— The whole of the sutures
were removed, as they kept up considerable
irritation ; the discharge from the wound passes
only by the small sinus opening on the right
side ; the upper edge of the flap still very thick,
owing perhaps to the slow circulation.

December 24th.— The wound looked less irri-
table.

December 25th and 26th. — Wound going on
well ; skin becomes rather thinner ; a small
pouch formed in the situation of the upper
suture.

December 27th.— The catheter again with-
drawn, and another introduced, which passed
with very little difficulty ; several hairs sprout-
ing out on the flap of skin ; the discharge still
continuing from the sinus ; the effect of pres-
sure was tried in preventing it, keeping the
sides together by a pad of lint bound down by
adhesive plaster.

IN THE URETHRA.

211

December 28th,— The compress has com-
pletely stopped the discharge by the sinus.

December 29th, 30th, and 31st. — Compress
applied daily ; no discharge from the sinus, but
the opening does not appear perfectly closed ;
matter still passes through the extremity of the
urethra ; the edge of the flap becomes gradually
thinner, beginning from that part which is least
twisted.

January 1st and 2nd, 1819.— The same.

— 3rd. — Passed a fresh catheter.

— 4th, — He sat up ; slight irritation in

the urethra ; matter tinged with blood.

January 5th. — Much pain and uneasiness in
the bladder and penis, relieved by a dose of
saline aperient medicine ; a quantity of urine
which passed through the urethra by the side
of the instrument produced no effect upon the
wound ; the same thing occurred in a greater
or less degree every day till this catheter was
discontinued on the 18th instant, and without
any apparent inconvenience.

January 10th. — Sat up without the instru-
ment, between three and four hours ; it was
afterwards withdrawn daily, but he was not al-
lowed to pass his water without it.

January 15th to 31st.— The catheter was
withdrawn for a few hours every day$ slight
discharge from the wound.

February 1st.— Had an evacuation from the
bowels during the time the instrument was out
of the bladder, attended with a considerable
discharge of urine by the natural passage, the
first time it had occurred since the operation ;

p 2

212

ON ABSCESS IN THE URETHRA.

not a drop of urine passed by the wound, and
no ill effects followed.

February 2nd to March 2nd. — As the flap of
integument and adjacent parts had still rather
an irritable appearance, and an occasional ooz-
ing was observed from a very small orifice on
the right side of the wound, it was thought im-
proper to hazard a repetition of this experiment ;
the catheter was therefore introduced twice a
day, and continued in the bladder at night.

March 3d. — By the direction of Mr. Cooper,
he now began to pass his urine without the aid
of an instrument, using it only once a day (to
prevent the return of an old stricture, of very
long standing, in the membranous part of the
urethra) ; after the first effort it came in a tole-
rably free stream, more so than it has done for
many years. A weak solution of sulphate of
zinc soon removed the irritable appearance of
the integuments.

May 8th. — A common bougie was substi-
tuted for the elastic catheter, and introduced
once every day till the latter end of September ;
since which time he has passed it but once in
two days; he is now, October 14th, in perfect
health, and very thankful for the operation ; the
stream of water becomes gradually fuller and
stronger ; the penis is somewhat drawn down
by the contraction of the integument, and the
small pouch which was formed by the ligatures
at the upper part of the flap is removed. I have
the greatest expectation that this operation will
in others be found useful, as this gentleman’s
wound has remained perfectly well for seven
months.

ESSAY III.

ENCYSTED TUMOURS.

By Mr. ASTLEY COOPER.

There are different species of encysted tumours
in the body, but that to which 1 at present in-
tend to confine my observations, is the tumour
which is situated just under the skin, and is so
frequently seen upon the head, the face, and
upon the back, and occasionally, but less fre-
quently, under the skin upon other parts of the
body.

Having been myself the subject of one of
these tumours, upon my back, I was led to ob-
serve it with more than common attention, and
am induced to hope that I shall be able to shew
from what source these swellings derive their
origin.

The encysted tumour is generally nearly glo-
bular,and when seated on the head feels very firm,
but upon the face it possesses a fluctuation more
or less obscure ; the skin over it is generally

Different

kinds.

Symptoms,

214

ON ENCYSTED TUMOURS®

Seat.

Number*

uni n flam eel, but it is now and then streaked with
blood-vessels, which are larger than those of the
surrounding parts.

In the centre of the tumour on the skin, it
often happens that in this early state, a black
or dark-coloured spot may be seen, which
sometimes continues through the whole course
of the disease, but this is by no means uni-
formly the case. In general they are unat-
tended with pain, are never in themselves dan-
gerous, and require removal from the parts in
which they occur, and the defect in appearance
they produce. They move readily within the
cellular membrane, if they are free from in-
flammation, but the skin in general does not
easily move over them.

The scalp is more subject to them than any
other part of the body, but they also frequently
are seen upon the face, and not unfrequently
one is found at the outer canthus. Upon the
shoulders they are often met with, more espe-
cially in men who wear braces, and in women
who have very tight shoulder-straps to their
stays. On the back they are occasionally formed,
and sometimes, but much less frequently, upon
the extremities.

The greatest number which 1 have seen in
the same individual, was in a patient of Mr.
Hall’s of Dulwich, who had sixteen upon his
head, some of which, as large as a walnut,
I removed. I have seen nine in another person,
and four, five, and six, are not uncommon.

The largest size I have known them acquire,
has been that of a common sized cocoa-nut,
and this grew upon the head of a man named

Size,

ON ENCYSTED TUMOURS.

Lake, who kept the house called the Six Bells at
Dartford. It sprung from the vertex and gave
him a most grotesque appearance, for when his
hat was put on, it was placed upon the tumour
but scarcely reached his head, and this man will
be, on this account, long remembered in that
neighbourhood. The cyst is in the collection
at St. Thomas’s Hospital, and an excellent cast
of his head, taken just prior to the operation.
He recovered very well and I believe is now
living, at least he was when I last inquired, and
it is now many years since the operation was
performed. In a relation of Mr. Toulmin of
Hackney, I saw one on the arm of very consi-
derable size, but in general these swellings
do not exceed from one to two inches diameter.

They are in some degree hereditary, for often
I hear a patient observe, I have several swellings
upon my head, and my father (or my mother)
had several.

They also occur in several of the same family.
I was asked by Dr. Paciflco to remove some
of these tumours from the head of one of a fa-
mily who resided near him in Bury Street, and
when I had accomplished this, another said, and
I will be obliged to you to do the same, and
then a third made the same request.

When these cysts are opened, a curd-like
substance is generally discharged from them,
having a sour and sometimes a most abomina-
bly offensive smell, if the swelling has under-
gone any change from inflammation.

When they acquire any size, there seems to
be an attempt made by nature for their remo-
val $ the skin inflames over them and the

21 S

Hereditary.

216

ON ENCYSTED TUMOURS.

Sudden de
crease.

Dissection,

swelling then becomes painful, ulceration slowly
follows, and the curdly substance mixed with
pus is discharged ; the opening sometimes
closes, but often remains fistulous, occasioning
some inconvenience to the patient.

When they have acquired their usual size,
from one to two inches diameter, they some-
times suddenly decrease, and then again begin
to enlarge and acquire their former magnitude.

Sometimes in combing the head, the tooth of
the comb is caught in the swelling, and a sup-
purative inflammation is in this way induced,
which removes the swelling for the time and
even sometimes permanently.

In dissecting these swellings, they are found
to adhere to the skin, but not upon the whole of
the surface firmly, but by the cellular membrane
only on the greater part of their surfaces.

The skin being removed, a cyst is found
which is embedded in the cellular membrane,
and extends from the skin to different depths,
according to the size of the swelling ; this cyst
is composed of a membrane differing in thick-
ness in the different parts of the body. If
placed on the face or near the canthus, the cyst
is thin so as to bear little pressure without
bursting, but if seated on the back it is much
thicker ; on the head it acquires the great-
est density, for on this part it is so thick
and firm as to maintain its form when its con-
tents are discharged, and so elastic that if it be
compressed, it expands itself readily to its
former size.

Within the cyst there is a lining of cuticle,
which adheres to its interior, and several des-

217

ON ENCYSTED TUMOURS.

quaminations of the same substance are formed
within the first lining, apparently secreted at
various periods of the growth of the cyst.

The substance which is contained within the
bag, has the character to the eye of coagulated
albumen, but as it varies much, this swelling
was formerly absurdly named, according to the
appearance of its contents, atheroma or meli-
ceris, a name which only expressed different
states of the substance contained in the same
disease.

If the vessels which nourish these cysts are
injected, they are found to be but of small size
although they are numerous.

These cysts sometimes contain hair when they Hair,
are situated upon the temple and near the eye-
brows, and in other hairy parts of the body;
the hairs have no bulbs or canal, and differ
therefore from those which are produced in those
surfaces of the body which naturally form hair#.

The cyst is sometimes ossified, and of one of
these I have given a view. (See Plate.)

From these cysts horny excrescences are Homy ex-
sometimes growing, and m the Plate I have
given a view of two of these, one of the natu-
ral size taken from a preparation in our Mu-
seum, and the other a section of one which I
removed from the pubes, and which is also in
the Anatomical Museum. For the former of
these I am indebted to my friend Dr. Roots, of
Kingston, who wrote me the following letter re-
specting the man, and who, before he operated,
had the kindness to send the patient for my in-
spection.

* These cysts in the sheep sometimes contain wool.

218

ON ENCYSTED TUMOURS.

66 MY DEAR SIR, \

u The case of Kennedy, the gardener, is as
follows :

“ In the year 1796, John Kennedy, a gar-
dener, in the service of the late Sir Richard Sul-
livan, Bart, of Thames Ditton, in the county of
Surrey, first perceived a tumour growing on the
upper part of his head, which was taken off by
the knife, in about three years from its first ap-
pearance, and shortly after this operation, a
horny substance began sprouting forth on the
same part, which continued increasing during
the four following years, till it accidentally fell
to the ground, whilst the patient was taking off1
his hat to some company walking in the gar-
dens, at which time it was not more than three
inches in length, and it was particularly ob-
served by myself and others, that the surface
from which it dropped, was perfectly smooth
and free from any discharge whatever. In a
few months from this time, a new horn began
to appear, putting on the figure and resemblance
of a ram’s horn, which I suffered to continue
growing during the seven following years, keep-
ing a constant watch upon its progress, and
expecting it would drop off* de se , when it had
arrived at a certain stage of maturity, and
which process had taken place under my own
observation in its former period.

“ But in the year 1811, the poor man suffering
greatly from its increasing inconvenience, and
becoming, in a measure, the laughing-stock of
his ignorant neighbours, I was induced, after
having shewn it in its living state to yourself to put

ON ENCYSTED TUMOURS.

219

an end to his misery, not only by amputating
the horn, but by dissecting out every portion of
the cyst, so as to prevent any fresh formation
of the horny matter, and in consequence of the
entire extirpation of the part, there has been
no appearance of the disease recurring up to this
date , which embraces an interval of eight years.
For a further account of this curious case, I
refer you to the article of Horny Excrescence in
Dr. Rees9s New Cyclopcedia . It has been stated,
that this identical gardener had another forma-
tion of the same nature, after the operation I
have just mentioned , but this statement is erro-
neous, as I have not lost sight of the man up to
the present time.

And I have the pleasure to be.

My Dear Sir,

much and truly yours,

w. roots/ *

Kingston on Thames ,

Oct . i 5th, i819.

Sir Everard Home has, in the Philosophical
Transactions for the year 1791, given an excel-
lent account of the growth of these horny ex-
crescences, and has clearly shewn they owe their
origin to these cysts.

The manner in which these horny excres-
cences grow is as follows : — The horn begins
to grow from the open surface of the cyst ; at
first it is soft, but soon acquires considerable
hardness , at first it is pliant, but after a lew

220

ON ENCYSTED TUMOURS,

Origin.

weeks, it assumes the character of horn : some-
times several of these grow from the same scalp*

In their removal it is necessary, to prevent
their recurrence, that the cyst as well as the
horn should be dissected out.

With respect to their origin, I believe this
tumour arises from a follicle extremely en-
larged and incapable of discharging its con-
tents from an obstruction of the orifice, by which
it opens on the surface of the skin.

A follicle is a glandular pore which are found
in numbers on the surface of the skin, more
especially about the face and head.

These follicles appear upon superficial exami-
nation to be only pores in the skin, but upon
the introduction of a fine probe they are found
to proceed through the skin into the cellular
membrane beneath it. They are productions
from the skin, and are lined naturally by cu-
ticle, and their internal surfaces secrete a seba-
ceous matter, which lubricates and defends the
surface of the skin upon which they are found.
This matter may be pressed from the follicles of
the nose in the form of worms, very consider-
ably longer than the skin is deep ; and there-
fore proving that these pores, extend beyond
the skin.

The first circumstance which induced me to
believe that an encysted tumour was an ob-
structed follicle, was examining a tumour of
this kind situated upon my own back. It had
acquired a diameter of about two inches, and
was situated at the lower part of the dorsal ver-
tebrae. I thought of requesting a friend to re-
move it, but examining it by means of two
mirrors,, I saw a small black spot in the centre

ON ENCYSTED TUMOURS.

221

of the swelling ; and picking this, I brought
out a piece of sebaceous matter with a black
head, like those seen on the nose. I then
squeezed the tumour, and through the orifice
occupied by the black sebaceous matter I emp-
tied the tumour, by squeezing out a large quan-
tity of sebaceous substance. This was effected
without pain, and without succeeding inflam-
mation, but gradually the secretion became re-
newed ; but by frequent pressure I have now
for several years kept it empty.

A lady applied to me with one of these swell-
ings upon her shoulder. It had a small black
spot upon its centre, through which I could
squeeze its curdly contents. I removed it with
the skin over it, and found that the opening
was a follicle leading into the hollow of an en-
cysted tumour, which contained sebaceous mat-
ter and lined with cuticle, and having a cyst of
the usual character. (See Plate.)

Often have I since seen the follicular aper-
ture over these swellings, by which the point of
a tent probe was readily admitted into the
cavity of the cyst, and through which I could
immediately squeeze its contents. The follicle
is however generally entirely obstructed at its
orifice, and a depression only is seen, (and not
always even this) when the sides of the swellings
are compressed.

These encysted tumours begin as follows
A follicle becomes obstructed at its termination
upon the skin. The secretion still proceeding,
its sides become extended in the cellular mem-
brane, where it can most easily yield ; and this
obstruction of its secretion produces a swelling
of greater or less magnitude, according to the

222

ON ENCYSTED TUMOURS*

degree of obstruction and the duration of the
disease. If it be said, how is it possible that a
follicle can be thus extended ? the answer is
this, other membranes expand to much greater
comparative magnitude. An ovarium, which
would not contain within its membrane more
than two drachms of water, will expand to a
magnitude capable of containing ninety-seven
pints, for of such an ovarium I have a prepara-
tion in our collection.

The cysts forming these swellings are more or
less dense according to the nature of the fol-
licle : as the skin of the head is very firm, so is
the cyst ; the skin of the back also produces
cysts of considerable thickness, but that on the
face is thin and delicate.

The cyst also acquires density according to
its duration, for constant pressure of it does
not produce high inflammation, and is known
to add to the density of parts.

Pressure is very frequently the cause of these
swellings, as is seen upon the shoulders, where
the braces produce them. I have also seen
them in the circle pressed upon by the hat, pro-
bably from some obstruction being thus pro-
duced at the extremity of the follicle. But in
a diseased state of the secretions, a want of due
moisture will produce the same effect, by in-
spissation of the substance secreted, and by
its incapacity to pass the orifice of the follicle.

When parts are exposed to pressure I have
seen the follicle obstructed at its mouth, di-
lating a little, but elongating still more, form-
ing a black head, and a worm of sebaceous
matter is thus formed of considerable magni-
tude. (See Plate.)

ON ENCYSTED TUMOURS. 223

The reason that these cysts do not inflame
when opened will now be seen ; they are natu-
rally external surfaces, that is, the follicles have
an aperture through the skin ; down this the
cuticle is reflected, and on its outer side is the
secreting portion of skin which forms the fol -
licle. All that is done then by opening them,
is to make their communication with the sur-
face of the skin more free, and the cuticle is
exposed, but not a new surface, and the cyst
will continue to secrete so long as any part of
it remains, just as the original follicle did.

Now also will be seen the reason for their
sudden diminution. They open at the follicle,
discharge and lessen, but the follicle becomes
again stopped, and the swelling is renewed.

With respect to their treatment, it consists Treatment,
in adopting the following rules. If the follicle
can be seen only as a black spot filled by
hardened sebaceous matter, a probe may be
passed through it, and the sebaceous matter
squeezed from the tumour, which is done with
little inconvenience.

But if violence would be required to squeeze
out the contents, inflammation will follow, and
the best plan is to make the opening larger,
and to squeeze out the contents of the cyst.

The relation of Mr. Toulmin, of Hackney,
had an encysted tumour upon her arm. I
thought too large for removal, and from this
the follicle was seen opening of considerable
size. I pressed out the contents of the swelling
by the aperture ; but finding the contents less
curdly than usual, I made a large opening, and
thus in a great degree emptied the swelling,
and directed her to continue to do so.

224

ON ENCYSTED TC MOORS.

Removal.

The common mode adopted for their remo-
val is, to dissect them out, but the best manner
of doing it is not to dissect them out whole, but
first to make an incision into them, and then by
pressing the sides of the skin together the cysts
may be easily everted and removed. If at-
tempted to be removed whole, the dissection is
most tedious, and before it is completed the
cyst is either cut or burst ; so many incisions
and so much pain may be readily avoided by
opening it freely by one incision, and taking
it between forceps to dissect it from its adhe-
sion to the surrounding cellular membrane.
When a swelling of this kind in the scalp is to
be removed, make an incision from one side of
the tumour to the other, directly through its
centre, and its contents, which are very solid
in this case, are directly discharged in form si-
milar to the tumour; then put a tenaculum into
the cyst, raise it, and it becomes most easily
separated. In half a minute the operation may
be accomplished, and with scarcely any pain.
The hair is then braided together from each
edge of the wound, and the edges are thus ap-
proximated being clotted together by means of
blood. Pressure upon the little vessels which
are divided in this simple operation wall be
sufficient to stop the bleeding.

The swelling of this description which takes
place at the outer canthus is the most difficult
of these encysted tumours to remove; it passes
within the orbit, and often adheres to its pe-
riosteum, and the inner part of the cyst is
with great difficulty reached in the operation.
This operation is always very tedious and
painful. The removal of cysts is not entirely

ON ENCYSTED TUMOURS.

225

unattended with danger ; I have seen three in-
stances of severe erysipelatous inflammation suc-
ceed the operation of removing these swellings
upon the scalp, and I believe it is owing to the
tendon of the occipitis frontalis being wounded
when they are attempted to be dissected out
whole. It is well known in cases of injury of
the head, that when this tendon is contused and
inflamed, the inflammation extends often over
the head and face. Trifling as the aperture ap»
pears, occasioned by this operation, care must
be taken for a few days after it, when the swell-
ing is seated upon the head. A lady had an
encysted tumour on the scalp removed ; three
days after she went into a cold bath ; soon
after she left the bath she was seized with a
rigor and severe pain in the head ; an erysipe-
latous inflammation succeeded upon the head
and face ; and notwithstanding she had promptly
the most able medical assistance in Dr. Baillie,
she fell a victim to this inflammation.

J>nztm fy If . TXjnurn

'ufttsheJ /; Z&taman.ffunrl. Itje.r. i '■>

jPfal'e f .

Fig- 2-

EXPLANATION OF THE PLATES,

PLATE I.

Shews fractures of the neck of the thigh-bone ;
the one from a wet, and the other from a
dried preparation.

Fig. 1.

Is a view of a fractured cervix, preserved in
the collection at St. Thomas’s Hospital.

Pubes.

b , Ischium.

c, Foramen ovale.

d , Trochanter major.

e , Trochanter minor.

Jl Os femoris.

g , Head of the bone broken at its cervix ;
little ossific projections seen on it ; and
ligament, effused by inflammation, ad-
heres to the bone.

/z, Fractured cervix absorbed in part, and
therefore much shortened.

z, Capsular ligament extremely thickened.

/r. Ligament adhering to the broken cervix.

Ligament effused from the synovial
membrane.

228

CONTINUATION OF

PLATE L

Fig. 2.

Is a view of a dried preparation in the anato-
mical collection at St. Thomas’s Hospital,

a. Pubes.

Ischium.

c, Foramen ovale.

d, Os femoris.

Cy Fractured cervix, shewing the shorten-
ing of the neck of the bone by ab-
sorption, and the cancelli unfilled by
bone.

jy The head and neck of the bone shews
the cancelli filled, and the broken bone
quite smooth.

A portion of the capsular ligament re-
mains connecting the os femoris to
the acetabulum.

Drawn fry 22, 2 homson .

Dublfrrked tyZcngm

2. \Brown , Ta-te mofle rJlow .

£ngf'i>y I, T, Wedgwood .

EXPLANATION OF

229

PLATE II.

Containing views of fractures of the neck of the
os femoris, from preparations which I have
sent to the collection at St. Thomas’s Hos-
pital.

Fig. 1.

Fracture of the neck of the thigh-bone within
the capsular ligament in the rabbit.

a , Head and neck of the thigh-bone.

by Neck and shaft of the thigh-bone ; sur-
faces smoothed, and some ligament
secreted upon them ; capsular ligament
thickened.

Fig. 2.

Fracture of the neck of the thigh-bone in the

dog.

ay Head of the bone.

by Its cervix.

Cy Capsular ligament thickened and inflam-
ed; the synovial membrane lining it
having the adhesive inflammation pro-
ceeding in it, and throwing out liga-
ment, which adheres to the head of
the bone ; a considerable quantity of
fluid was formed on this joint.

Fig. 3.

Shews the os calcis broken near the insertion of
the tendo achillis, and the bone drawn up by
the action of the muscles.

Os calcis.

by Broken and elevated portion of bone.

230

CONTINUATION OF

PLATE IL

c , Ligament formed instead of bone, to
unite the elevated portion to that from
which it had been separated.

Fig. 4.

Os femoris of the human subject broken through
the trochanter and neck externally to the
capsular ligament.

At a , the oblique union is seen, and if the
condyles are compared with the head
of the bone, it will be seen that the
knee and foot had been suffered to
be turned much outwards, which, with-
out care in this fracture, is very liable
to happen.

Fig. 5.

Head and neck of the thigh-bone of a dog split
down and afterwards united, but unevenly ;
the union has been effected at the cancelli
with scarcely any change upon the surface of
the bone ; and the union at the neck of the
bone is firmer than at its head,

a , Head of the bone.

by Broken head of the bone and its cervix.

Part of the fracture was within a part external
to the capsular ligament.

Tiafre 3 . .

S’ufrlcyh&i fry 2.tmgmcLTir7fuTjt~,7Leej,07~rne Sc Bj'cwii , Paternoster -7iow

EXPLANATION OF

231

PLATE III.

Shewing a dislocation of the knee-joint ; in
which the thigh-bone was thrown outwards and
backwards.

a9 Patella.

b9 Head of the tibia.
cc, Semilunar cartilages.
d, Articular surface of the os femoris.
ey Capsular ligament.

f, Lacerated vastus internus muscle.

g, Place of amputation.

232

EXPLANATION OF

PLATE IV.

Views of transverse and longitudinal fractures

of the patella.

Fig. 1.

Shews the patella broken transversely in the
human subject and united by ligament®

a , Upper portion of the bone.

&, Lower portion®
c, Ruptured ligament.

From h to c is the new ligament uniting the

bones®

Fig. 2.

A transverse fracture of the patella, which I
produced in the dog, shewing the new and
uniting ligament.

Fig. 3 .

Shews the appearance for the first week after
this experiment. Blood is effused, which is
gradually absorbed.

Fig. 4®

Is a view of the fracture after a fortnight, shew-
ing the adhesive matter producing the liga-
mentous union.

Fig. 5.

Shews the new ligament after three weeks, ex-
tending from a to b .

Fig. 6.

Is a view of a longitudinal fracture of the pa-
tella which I produced in the dog ; from a
to h is the new ligament by which the bone
was united.

Fig- 1.

FIa7& 4-

Ftg . 3.

Fog. 4-.

Fcg . 4.

Fig. 7 .

CONTINUATION OF

233

PLATE IV .

Fig. 7*

Shews the longitudinal fracture of the patella
united by bone ; the parts having remained
in contact because the division had not been
extended to the muscles a or ligament
c is the ossific union ; some cartilage re-
mained not yet ossified, ,By the side of this
Fig, is seen the patella after maceration, to
shew the ossific union when the cartilage was
macerated away.

Fig. 8.

Shews the leather strap for the fractured pa-
tella.

Fig, 9.

Exhibits other bandages for the fractured pa-
tella. The lateral, the most frequently used,
confined by rollers above and below, which
are approximated by tying the lateral tapes.
The broader tape used in the fore part of the
patella is also seen.

Fig. 10.

Shews the bandage applied for partial disloca-
tions of the knee, and the rollers unapplied
to shew the form of the bandage.

234

EXPLANATION OF

PLATE V .

Exhibits the partial dislocation of the tibia for-
wards upon the astragalus, which I have de-
scribed.

Fig. 1.

a, Tibia.

b , Astragalus.

c, New articulatory surface and end of the

tibia.

d , The original articulating surface of the

astragalus.

Fig. 2.

Opposite view of the same preparation.

a , Tibia.

b , New articulatory surface of the tibia.

c, Astragalus,
r/, Fibula.

e, Malleolus externus of the fibula, which

had been broken off, and has been ir-
regularly united.

,/J Former articulating surface of the astra-
galus.

EXPLANATION OF

285

PLATE VL
Fig. 1.

Shews the dislocation of the tibia at the ancle-
joint inwards ; the leg was amputated for this
accident.

Tibia thrown from the astragalus.

b, Tibia, broken at its junction with the

fibula.

c , Fibula.

cl , Portion of the broken tibia.
e , Broken end of the fibula or malleolus
externus.

f. Articulatory surface of the astragalus.

Fig. 2.

♦

Shews a dislocation of the tibia outwards ; this
accident had been partially reduced.
a , libia.
bj Fibula.

c, Os calcis.

d , Broken end of the tibia at the malleolus

internus.

ey Broken end of the fibula at the malleolus
externus.

Tibia thrown on the side of the astraga-
lus, and it is anchylosed in that situa-
tion.

236

EXPLANATION OF

PLATE VIL

Exhibits views of encysted tumours and their
^productions*

Fig. 1.

Shews an encysted tumour of the usual size.

The cuticular lining of the cyst*

A flap of the cyst turned back to shew
its interior*

Fig. 2.

Shews one of these tumours from the head with
the cyst opened to shew its thickness, and its
lining in part peeled off

Fig. S.

Is a cyst which shews hairs in its interior ; this
cyst was growing just at the outer end of the
eyebrow.

Fig. 4.

Shews the cyst ossified, which sometimes hap-
pens in those which have existed long.

Fig. 5.

A cyst with a follicle over it, filled with dried
sebaceous matter, and this follicle directly
opens into the interior of the cyst, of which
it is a part.

Fig. 6.

A portion of the skin with a cyst adhering
to it. In the skin the follicle is seen which
opens into the cyst, and a bristle is intro-
duced to shew its passage into the cyst.

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Fig . 2

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£, &-B rown, Tale rrzoster Ttow

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'JBrcwH , fkte medterJto w .

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CONTINUATION OF

PLATE VII.

-'~Jv

N,%

Fig. 7.

A follicle beginning to enlarge, and its open
extremity filled with sebaceous matter, and
the distended follicle stretched under the skin®

Fig® 8®

A horn of the size which it had acquired when
removed from the head, (See Br. Root’s
Case,) the hair of the scalp surrounding its
root ; the horn curled at the end® This is
preserved in the collection at St® Thomas’s
Hospital*

Fig. 9.

Section of a horn I removed, which was lami-
nated internally, as is here shewn.

238

EXPLANATION OF

PLATE VI IL

Fig. 1.

Sketch of a fracture of the cervix femoris,
within the capsular ligament.

a , Head of the bone.
by Cervix, broken,
c, Capsular ligament.

Fig. 2.

Fracture of the neck of the bone and trochan-
ter externally to the ligament.
a , Head of the bone.
by Thigh-bone.

c, Fracture through the trochanter.

Fig. 3.

View of a preparation sent me by Mr. Oldknow.
a. Head of the bone.
by Trochanter broken off.

Cy Trochanter minor broken.
dy Cervix femoris broken at its junction
with the trochanter.

Cy Thigh-bone.

Fig. 4.

Section of a broken cervix at the trochanter,
given me by Mr. Roux.

ciy Head of the bone.
by Trochanter major.

Cy Thigh-bone.

dy dy Broken cervix sinking into the cancelli,
and there united by bone.

CONTINUATION OF

PLATE VIII.

Fig. 5.

The machine which has been for near twenty
years used in Guy’s Hospital, for fractured
thighs, simplified from the invention of Mr.
White of Manchester, and Mr. James of
Hoddesdon.

a , Stand.

b , Additional pieces to it to give firmness.

c, One portion of the inclined plane.

cl , The other portion.

e> The joint.

Fig. 6.

Shews a fracture of the os femoris, a little below
the trochanter minor, and a most miserable
union of the bone from inattention to posi-
tion. This is the case in which the knee
must be much raised, and the body preserved
in a sitting position, as far as the patient can
bear it.

Fig. 7.

Dislocation of the knee from ulceration, in
which the tibia is thrown forwards at right
angles with the os femoris.

ciy Os femoris.

by Tibia.

c, Fibula.

dy Patella anchylosed.

6y Ligament of the patella.

END OF PA&T II.

239

G. WOODFALL, PRINTER,

ANGEL COURT, SKINNER STREET, LONDON.

_£np ? iy nner /y.

Jfrixt*n 2ry I^.Thomfxtern

7”. r.nn/rm/M Jfurvl-.Jfee

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